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Patient information

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Billing information

Chief Complaint

Eye History



Contact Lens Wearers only


Family Eye History


Adult History

Please choose from the menu options or select the option to type in your own text. Thank you!


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Strabismus / Amblyopia

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Brain Injury

What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?


Brain Injury Vision Symptom Survey

Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4



If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:




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Dry Eye



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Reading and Computer Symptom Checklist


CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)


Please answer the following questions about how your eyes feel when reading or doing close work.


NOTE: if the patient is a child, please read the instructions and then each item exactly as written.


Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4


Check All That Apply:



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Dizziness And Motion Sensitivity Checklist


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