Online Patient Forms

Click here to return to the the previous website.

You need to complete three tabs and the Submit Data tab:

  1. Demographics tab
  2. Age-appropriate intake tab
  3. One of the services tabs - Neuro, Vision Therapy or Low Vision

The LAST STEP is to click on the Submit Data tab and click the SUBMIT DATA button. You cannot save your information and return at a later time, so please allow at least 15 minutes to complete and submit your information in one session.


Please call our office at (913) 469-8686 if you have questions about which tabs to complete. After completing the tabs that correspond to your appointment, please submit your data on the last tab "Submit Data."

If you have Original Medicare or BlueCross BlueShield, we'll make a copy of your insurance card at your appointment. Thank you!

Demographics


Patient Information
FirstLastMISuffixNickname
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?
FirstLastMISuffix
Address

CityStateZipCode
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?
OTPTSpeech
Currently in OTCurrently in PTCurrently 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
OTPTSpeech
Currently in OTCurrently in PTCurrently 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?

Submit Data