Kansas City Vision Performance Center - Crystal PM Patient Forms

Demographics

Patient Information

First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:		Cell Phone:
Email		Preferred Contact Method:

Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
		Misc/Guardian

Billing Information Is The Billing Address the Same?

First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Infant to Age 4 History

Infant/Child's Overall Health

Rate your child's overall health (10 = Excellent)

Please describe any current or past health problems your child has experienced.

Reactions to immunizations?

If yes, please describe (including allergies to medications).

Please list all medications your child is currently taking:

Previous Eye Care
If your child has had an eye exam, please tell us when the most recent exam was.

Who is your optometrist or what is the clinic name?

Infant/Toddler Developmental Milestones

Crawling		Hearing
Walking		Speech

Has or does your child receive special development assistance?

OT	PT	Speech
Currently in OT	Currently in PT	Currently in Speech

Please note other special development help, previous and/or current.

Can your child identify: Colors Letters Numbers

If speech was delayed, can he/she speak clearly now?		Is your child color blind?
Can he/she understand and respond to spoken language?		What is your child's dominant hand?
Does your child like to be read to?		Does your child feel that he/she has a problem?

Please describe your child's home environment, such as who lives in the home?	Are there any additional home/environment changes we should know about?
Please describe your child's general behavior, personality, parent/sibling/social interactions, etc.	Is there anything we can do to make your child's visit more comfortable? (Physical needs, calm fears, etc.)

Child History

Child's Overall Health

Rate your child's overall health (10 = Excellent)

Please describe current or past health problems your child has experienced.

Has your child had reaction to any immunizations or medications?

If yes, please describe (allergies to medications):

Please list all medications your child is currently taking.

Previous Eye Care
If your child has had an eye exam, please tell us when the most recent exam was.

Who is your optometrist or what is the clinic name?

Child's Developmental Milestones

Crawling		Hearing
Walking		Speech

Special Development Assistance

OT	PT	Speech
Currently in OT	Currently in PT	Currently in Speech

Please note other special development help, previous and/or current.

Can your child identify: Colors Letters Numbers

If speech was delayed, can he/she speak clearly now?		Can he/she understand and respond to spoken language?
Does your child like to read?		Can your child keep rhythm?
Does your child like to be read to?		Does your child feel that he/she has a problem?
At what grade level is your child reading?

What activities does your child participate in?

Music	Art	Sports	Martial arts
Dance	Theater	Gymnastics	Other

What grade is your child current in? (Tell us the grade most recently completed if on summer break.)
Has your child repeated any grade(s)?
Is your child in a regular classroom?
Does your child require full or part time classroom assistance?

Child's Home & School Behavior

Please describe your child's home environment, such as who lives at home?.	Are there any additional home/environment changes we should know about?
Describe any behavior problems at home.	Is your child having difficulty at school? If so, please describe.
Is there anything we can do to make your child's visit more comfortable? (Physical needs, calm fears, etc.)

Adult History

Reason for Your Visit

What brings you to our office?	When did your vision problems begin?
Please describe how your vision has changed?	How does it affect your daily activities?
Have your vision problems changed recently?
Does your vision fluctuate from day to day?	Yes No
Are your vision problems hereditary?	Yes No

Previous Eye Care
When was your last eye exam and/or ophthalmologist exam?

Who is your eye doctor and the clinic name?

Family Eye History

		Family Member			Family Member
Macular Degeneration	Yes No		Diabetes	Yes No
Retinal Detachment	Yes No		Glaucoma	Yes No
Cataracts	Yes No

Other

Systems Review

Neurological		Ears, Nose, Mouth, Throat		Cardiovascular
Headaches/Migraines	No Yes	Allergies/Hay Fever	No Yes	High Blood Pressure	No Yes
Seizures	No Yes	Hearing Sensitivity	No Yes	Chest Pains	No Yes
Dizziness/Balance	No Yes	Imbalance	No Yes	Shortness of Breath	No Yes
Memory	No Yes	Psychiatric		Swelling of Legs	No Yes
Processing Difficulties	No Yes	Depression / Mood Swings	No Yes	Palpitations/Faintness	No Yes
Concentration	No Yes	Anxiety	No Yes	Respiratory
		Bones / Joints / Muscles		Asthma	No Yes
		Arthritis	No Yes	Emphysema	No Yes
				COPD	No Yes

Please list all medications you are currently taking as well as allergies to medications.

Surgery - Accidents - Illness

Please describe any illnesses, injuries, or surgeries you are currently managing or have recently experienced.
On a scale of 1 to 10, how would you rate your overall health? (10 = Excellent)

Neuro Vision Intake

Neuro Event

What is the month/year of the neurological event relating to your visit today OR was it a gradual onset?
Were your injuries caused by a car accident?
If yes, in what city and state did the accident occur?
Is your care being provided through a Workers Comp policy?
Please describe your recent injuries, medical event, or concerns.

Please describe how your injuries are affecting your body and overall health.

Please describe your hospitalization, recovery, and therapies.

Please list any previous injuries (and approximate dates) that may be relevant to your visual or other performance.

What are your specific vision concerns (if not listed above)?

On a scale of 1 to 10, rate your quality of life after your neuro event. (10 = Excellent; Life is perfect.)

Who referred you to our office?

Vision Symptoms: Please check only the symptoms that apply.

Eyesight Clarity		Visual Comfort
Distance vision is blurred Without lenses With lenses		Eye discomfort, sore eyes, eye strain
Near vision blurred Without lenses With lenses		Headaches or dizziness after doing visual tasks
Vision clarity changes or fluctuates during the day		Eye fatigue / Physically tired after using eyes all day
Poor night vision / can't see well to drive at night		Feel "pulling" around eyes

Reading / Computer / Tablet		Double Vision
Short attention span, easily distracted when reading		Double vision - especially when tired
Slow reading		Have to close or cover one eye to see clearly
Poor comprehension, can't remember what was read		Print moves in and out of focus when reading
Confusion of words, skip words when reading
Lose place and use finger, ruler, etc. to keep place when reading		Depth Perception
Can't read as long as I like/need to		Clumisness or misjudge where objects are
		Lack of confidence walking, missing steps, or stumbling
Peripheral Vision		Poor handwriting - spacing, size, legibility
Side vision is distorted, objects move or change position
What appears straight ahead of me isn't always where it actually is		Dry Eyes
Avoid crowds, can't tolerate "visually busy" places		Eye feel "dry" and sting
		Have to rub eyes a lot
Light Sensitivity
Normal indoor light is uncomfortable
Outdoor light is too bright

Please share additional concerns, visual or other:

Vision Therapy Intake

Vision History
Please describe the vision complaints you are here to resolve.

When did the problem begin?

Does anyone in the family have a similar problem? Please list family members.

What is your current glasses or contacts prescription?

Who referred you to our office?

Please tell us which doctors listed above should receive reports. List additional doctors, therapists, or teachers that should receive reports.

Previous Therapy
Has the patient done Vision Therapy in the past? No Yes

If yes, please describe the treatment program recommended adn the results.

Please list any other therapy programs that have been recommended.

Is there any other information you'd like to share?

Low Vision Rehab Intake

Vision History

What are your curent vision concerns?

What is your current lens prescription, and how long have you been wearing it?

Who referred you to our office?

Please list the doctors you would like reports sent to.

Low Vision History
Have you had previous low vision care?

Are you currently using any low vision devices?

Do you currently drive?

If no, do you wish to regain driving priviledges?

What is your current living situation?

What are your goals for low vision rehabilitation?

Online Patient Forms