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Glare
Eye ache
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Redness Burning Light Sensitivity Tearing / Watery eyes Stinging Grittiness Dryness Mattering on your eyelids when you wake up in the morning Dry Mouth Eye lids swollen or red along the lash margin Night Driving Problems Burning in the morning Decreased contact lens wearing time Vision fluctuates from clear to blurry especially in the morning after reading, watching TV, computer use, or driving. Artificial Tear drops help but do not last long enough Do you take Omega-3 supplements daily? Do you use Visine or other "get the red out" drops? How often? Have you ever been prescribed RESTASIS eye drops? Vision Therapy History Do you observe or does your child report any of the following? Headaches Blurred Vision Double Vision Eyes "hurt" or "tired" Nausea when doing visual tasks Motion Sickness / Car Sickness Bothered by light / sun light Frequent styes Eyes itch Eyes burn Eyes tear Eyes frequently reddened Closing or covering one eye Loses place while reading Poor reading comprehension When reading, letters/words appear to move or float around Loses attention easily Are there any other complaints your child makes concerning vision? Do you have any other concerns / observations concerning your child's vision? Child History: Medical History Is your child especially afraid of Doctors: Yes No Is your child generally healthy? Yes No Average Below Average Type in your own text List significant illnesses, bad falls, high fevers or chronic illnesses: Event/Condition...Age...Severity...Complications: Event/Condition...Age...Severity...Complications: Neuro/psych eval: Yes No By Whom? Occupational Therapy eval? Yes No By Whom? Developmental History: Length of Pregnancy Type of delivery: None Natural Caesarian Type in your own text Forceps / Vacuum Anesthesia During pregnancy of this child, did any of the following occur: toxemia trauma use of alcohol injury by fall smoking use of drugs severe illness prescription medication little obstetrical care other Please explain: Child's birthweight: lbs. and ozs. Apgar score: @ birth after 10 minutes My Chil Is: biological adopted At what age? foster other Explain: Skills/ Milestones: GROSS MOTOR Activity Average Age Your Child Rolled over 3.5 months Early Late Normal Unsure Type in your own text Sits w/out support 6.5 months Early Late Normal Unsure Type in your own text Walks unaided / alone 12 months Early Late Normal Unsure Type in your own text Kicks a ball 18 months Early Late Normal Unsure Type in your own text Toilet trained 24 months Early Late Normal Unsure Type in your own text Rides tricycle 3 years Early Late Normal Unsure Type in your own text FINE MOTOR Activity Average Age Your Child Reaches / grasp for object 4 months Early Late Normal Unsure Type in your own text Scribbles spontaneously 15 months Early Late Normal Unsure Type in your own text Stacks / Piles blocks 18 months Early Late Normal Unsure Type in your own text Eats with a fork/spoon 3 years Early Late Normal Unsure Type in your own text LANGUAGE Activity Average Age Your Child Smiles spontaneously 1 month Early Late Normal Unsure Type in your own text Says single words 12 months Early Late Normal Unsure Type in your own text Refers to self by first name 18 months Early Late Normal Unsure Type in your own text Knows full name 3 years Early Late Normal Unsure Type in your own text How is your child performing compared to others his/her age: Above average Average Below average Type in your own text How well developed is your child's spoken vocabulary? excellent very well developed average behind delayed Type in your own text Has your child undergone any of the following testing/treatment/therapy? Educational: Yes No Neurological: Yes No Psychological: Yes No Occupational: Yes No Speech / Auditory: Yes No Physical: Yes No If yes, please list all previous evaluations done on your child: Current grade in school: School: What is their favorite subject? 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 1. Do your eyes feel tired when reading or doing close work? 0 1 2 3 4 2. Do your eyes feel uncomfortable when reading or doing close work? 0 1 2 3 4 3. Do you have headaches when reading or doing close work? 0 1 2 3 4 4. Do you feel sleepy when reading or doing close work? 0 1 2 3 4 5. Do you lose concentration when reading or doing close work? 0 1 2 3 4 6. Do you have trouble remembering what you have read? 0 1 2 3 4 7. Do you have double vision when reading or doing close work? 0 1 2 3 4 8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work? 0 1 2 3 4 9. Do you feel like you read slowly? 0 1 2 3 4 10. Do your eyes ever hurt when reading or doing close work? 0 1 2 3 4 11. Do your eyes ever feel sore when reading or doing close work? 0 1 2 3 4 12. Do you feel a 'pulling' feeling around your eyes when reading or doing close work? 0 1 2 3 4 13. Do you notice the words blurring or coming in and out of focus when reading or doing close work? 0 1 2 3 4 14. Do you lose your place when reading or doing close work? 0 1 2 3 4 15. Do you have to reread the same line of words when reading? 0 1 2 3 4 Check All That Apply: Tendency to close or cover one eye Reverses or forgets letters, numbers or words Head tilt or movement Confuses similar looking words Poor reading comprehension Difficulty recognizing the same word in the next paragraph Head too close to the paper while reading or writing Poor spelling Difficulty tracking moving objects, balls, etc... Poor visual-motor(eye-hand/foot) coordination Writing is crooked or poorly spaced Confuses right and left Misalignment of digits or columns of numbers Difficulty following a sequence of directions Errors copying from chalkboard, computer or book Whispers when reading silently Avoids near work or reading Comprehension decreases over time Difficulty completing assignments in time allotted Does not visualize Strabismus / Amblyopia (If applicable): At what age was the eye turn first noticed? Did it start suddenly or gradually? Which direction does the eye turn (check all that apply)? In Out Up Down Which eye turns? Right Left Both Is the eye turn getting worse, better or no change? When does the eye turn (always, what % of time, when tired, when ill, etc)? Does the eye turn more when looking:? Up close In the distance To the left To the right Up Down Do you ever notice one or both eyes shaking rapidly? If patching treatment was prescribed, please describe at what age patching was started, how it was done, the eye patched, for how long, and an estimate of the results Has there been any surgery? Yes No If yes, estimate the results: Please describe any visual therapy, including duration of treatment, age at which it was started and estimate the results: Dizziness And Motion Sensitivity Checklist (If applicable): Nausea, headache or dizziness when reading in the car even on a STRAIGHT road Nausea, headache or dizziness when sitting close to a movie screen or watching a train go by Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days) Frequent, sometimes daily, headache or 'pressure' in your head Nausea, headache, dizziness or spacey feeling when shopping or moving through crowds of people Unusual fear of heights Lose your place easily when reading Flickering lights bother you (light through trees when driving or fluorescents) Avoidance of driving because of car sickness TBI History (If applicable): Date of most recent event: Briefly describe the injury: What part of the head was affected: Forehead Right side Left side Back of head Top of head Face Was there loss of consciousness? For how long? When did you first see a doctor regarding your accident / injury? Were you hospitalized? Describe any previous injuries and dates: What Types Of Professional Care Have You Received or Are Receiving Due To This Injury? (List care such as neurological, psychological, occupational therapy, physical therapy, speech, auditory, chiro, osteopathic, accupuncture, neuro feed back): What is your most significant visual concern at this time? Brain Injury Vision Symptom Survey Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4 Eyesight clarity 1. Distance vision blurred and not clear -- even with lenses 0 1 2 3 4 2. Near vision blurred and not clear -- even with lenses 0 1 2 3 4 3. Clarity of vision changes or fluctuates during the day 0 1 2 3 4 4. Poor night vision / can't see well to drive at night 0 1 2 3 4 Dry eyes 1. Eyes feel 'dry' and sting 0 1 2 3 4 2. 'Stare' into space without blinking 0 1 2 3 4 3. Have to rub the eyes a lot 0 1 2 3 4 Visual comfort 1. Eye discomfort / sore eyes / eyestrain 0 1 2 3 4 2. Headaches or dizziness after using eyes 0 1 2 3 4 3. Eye fatigue / very tired after using eyes all day 0 1 2 3 4 4. Feel 'pulling' around eyes 0 1 2 3 4 Depth perception 1. Clumsiness / misjudge where objects really are 0 1 2 3 4 2. Lack of confidence walking / missing steps / stumbling 0 1 2 3 4 3. Poor handwriting (spacing, sizing, legibility) 0 1 2 3 4 Doubling 1. Double vision -- especially when tired 0 1 2 3 4 2. Have to close or cover one eye to see clearly 0 1 2 3 4 3. Print moves in and out of focus when reading 0 1 2 3 4 Peripheral vsion 1. Side vision distorted / objects move or change position 0 1 2 3 4 2. What looks straight ahead -- isn't always straight ahead 0 1 2 3 4 3. Avoids crowds / can't tolerate 'visually busy' places 0 1 2 3 4 Light sensitivity 1. Normal indoor lighting is uncomfortable 0 1 2 3 4 2. Outdoor light too bright -- have to use sunglasses 0 1 2 3 4 3. Indoors fluorescent light is bothersome or annoying 0 1 2 3 4 Reading 1. Short attention span / easily distracted when reading 0 1 2 3 4 2. Difficulty / slowness with reading and writing 0 1 2 3 4 3. Poor reading comprehension / can't remember what was read 0 1 2 3 4 4. Confusion of words / skip words when reading 0 1 2 3 4 5. Lose place / have to use finger not to lose place when reading 0 1 2 3 4 If you experience any of the symptoms below, please check if the symptom was present before the injury or only after: Before After Dizziness or motion sickness Difficulty understanding what is seen Difficulty recognizing words Difficulty recognizing faces Difficulty remembering names of objects Difficulty remembering people's names Difficulty with time management Difficulty finding objects when grouped together Patterned wallpaper or carpets are bothersome Awkward or poor balance Ears ringing / Tinnitus Confusion / Disorientation Gets lost often Bothered by noises Bothered by touch Before After Dislike heights Difficulty using both sides of the body together Memory problems Difficulty focusing one or both eyes Frequent squinting or blinking Vision appears unstable or shifts from eye to eye Unusual head tilt or turn Portions of a page or objects appear to be missing People or things suddenly appear unexpectedly from one side Looking to the side of objects to see them better Tunnel vision One eye turns in, out, up, or down Flashes of light Difficulty concentrating on visual tasks Difficulty maintaining eye contact What activities can you no longer engage in due to your accident / injury? Communication Consent and HIPAA Privacy Notice Please view the document by clicking the blue link, review and sign in the designated arew below on this tab, Thank you! View Privacy Receipt, Communication Consent and HIPAA Privacy Notice Form Yes, I give permission to the Optometric Vision Development Center to communicate with me using the following methods: [CLICK ALL THAT APPLY: Email, phone, text, alternative phone numbers listed (i.e. home/work)] Email Phone Call Alternative Phone Number Text Signature Date Receipt of Notices of Privacy Practices Signature Date Submit Data
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Nausea when doing visual tasks
Motion Sickness / Car Sickness
Bothered by light / sun light
Frequent styes
Eyes itch
Eyes burn
Eyes tear
Eyes frequently reddened
Closing or covering one eye
Loses place while reading
Poor reading comprehension
When reading, letters/words appear to move or float around
Loses attention easily
Is your child especially afraid of Doctors: Yes No
Neuro/psych eval: Yes No
Occupational Therapy eval? Yes No
Forceps / Vacuum
Anesthesia
toxemia
trauma
use of alcohol
injury by fall
smoking
use of drugs
severe illness
prescription medication
little obstetrical care
other
biological
adopted
foster
Yes
No
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:
Tendency to close or cover one eye
Reverses or forgets letters, numbers or words
Head tilt or movement
Confuses similar looking words
Difficulty recognizing the same word in the next paragraph
Head too close to the paper while reading or writing
Poor spelling
Difficulty tracking moving objects, balls, etc...
Poor visual-motor(eye-hand/foot) coordination
Writing is crooked or poorly spaced
Confuses right and left
Misalignment of digits or columns of numbers
Difficulty following a sequence of directions
Errors copying from chalkboard, computer or book
Whispers when reading silently
Avoids near work or reading
Comprehension decreases over time
Difficulty completing assignments in time allotted
Does not visualize
In
Out
Up
Down
Right
Left
Both
Up close
In the distance
To the left
To the right
Nausea, headache or dizziness when reading in the car even on a STRAIGHT road
Nausea, headache or dizziness when sitting close to a movie screen or watching a train go by
Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days)
Frequent, sometimes daily, headache or 'pressure' in your head
Nausea, headache, dizziness or spacey feeling when shopping or moving through crowds of people
Unusual fear of heights
Lose your place easily when reading
Flickering lights bother you (light through trees when driving or fluorescents)
Avoidance of driving because of car sickness
Forehead
Right side
Left side
Back of head
Top of head
Face
What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?
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:
Email
Phone Call
Alternative Phone Number
Text