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 |
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Hearing |
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Walking |
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Speech |
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Has or does your child receive special development assistance?
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? |
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Is your child color blind? |
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Can he/she understand and respond to spoken language? |
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What is your child's dominant hand? |
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Does your child like to be read to? |
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Does your child feel that he/she has a problem? |
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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 |
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Hearing |
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Walking |
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Speech |
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Special Development Assistance
Please note other special development help, previous and/or current.
Can your child identify: Colors Letters Numbers
What activities does your child participate in?
Child's Home & School Behavior
Neuro Vision Intake
Neuro Event
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 |
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Visual Comfort |
Distance vision is blurred
Without lenses
With lenses |
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Eye discomfort, sore eyes, eye strain |
Near vision blurred
Without lenses
With lenses |
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Headaches or dizziness after doing visual tasks |
Vision clarity changes or fluctuates during the day |
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Eye fatigue / Physically tired after using eyes all day |
Poor night vision / can't see well to drive at night |
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Feel "pulling" around eyes |
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Reading / Computer / Tablet |
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Double Vision |
Short attention span, easily distracted when reading |
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Double vision - especially when tired |
Slow reading |
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Have to close or cover one eye to see clearly |
Poor comprehension, can't remember what was read |
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Print moves in and out of focus when reading |
Confusion of words, skip words when reading |
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Lose place and use finger, ruler, etc. to keep place when reading |
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Depth Perception |
Can't read as long as I like/need to |
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Clumisness or misjudge where objects are |
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Lack of confidence walking, missing steps, or stumbling |
Peripheral Vision |
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Poor handwriting - spacing, size, legibility |
Side vision is distorted, objects move or change position |
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What appears straight ahead of me isn't always where it actually is |
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Dry Eyes |
Avoid crowds, can't tolerate "visually busy" places |
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Eye feel "dry" and sting |
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Have to rub eyes a lot |
Light Sensitivity |
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Normal indoor light is uncomfortable |
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Outdoor light is too bright |
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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?
Submit Data
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