Patient Forms

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Were you referred to our office? Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Child History

-----Pediatric Eye Health History------Please Complete For Your Child------------------------------------------------------------------

Child's Full Name:

Child's Preferred Name:

Mother/Caretaker's Name:		Occupation:		Bus. Phone:
Father/Caretaker's Name:		Occupation:		Bus. Phone:

My Child is:
Biological
Adopted - At What Age?:
Foster
Other - Explain:

______________________________________________________________________________________________________________________________________________________

Visual History

Main reason for having an examination today:
Date of last evaluation: Doctor's name:
Reason for examination:
Results/Recommendations:
Were glasses, contact lenses or other optical devices recommended? If yes, are they used? If yes, when?
If no, why not?

Do you observe or does your child report any of the following?

Headaches	Blurred Vision
Double Vision	Hurt/Tired Eyes
Nausea when doing visual tasks	Motion Sickness/Car Sickness
Bothered by Light/Sunlight	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?

______________________________________________________________________________________________________________________________________________________

Medical History

Pediatrician's Name: Is your child especially afraid of Doctors: Yes No
Last Visit Date: For What Reason? Is your child generally healthy?
Medications (including vitamins & supplements):
Allergies to Medications:
______________________________________________________________________________________________________________________________________________________

List significant illnesses, bad falls, high fevers or chronic illnesses:

Event/Conditions...Age...Severity...Complications:
Event/Conditions...Age...Severity...Complications:

______________________________________________________________________________________________________________________________________________________

Neurological/Psych Eval:	Yes	No -	By Whom?:
Occupational Therapy Eval:	Yes	No -	By Whom?:

______________________________________________________________________________________________________________________________________________________

Poor Vision:	Child	Family	If Family, who?
Strabismus:	Child	Family	If Family, who?
Amblyopia:	Child	Family	If Family, who?
Cancer:	Child	Family	If Family, who?
Epilepsy/Seizures:	Child	Family	If Family, who?
Learning Issue:	Child	Family	If Family, who?
Blindness:	Child	Family	If Family, who?

Other:
______________________________________________________________________________________________________________________________________________________

System Review

Notices Or Complains Of:			Does Child Have Or Had:
Eye Turns In/Out:	Yes	No	Eye Injury or Surgery:	Yes	No
Squints/Blinks a lot:	Yes	No	Lazy Eye/Amblyopia:	Yes	No
Covers/Closes One Eye:	Yes	No	Patching:	Yes	No
Lacks Interest in Looking at Objects:	Yes	No	Vision Therapy/Orthoptics:	Yes	No
Rubs Eyes Excessively:	Yes	No	Surgery/Hospitalizations:	Yes	No
Reddened or Encrusted Eyelids:	Yes	No	Breathing Problems:	Yes	No
Eyelid Droops:	Yes	No	Gastointestinal Problems:	Yes	No
Poor Tracking/Eye Movements:	Yes	No	Musculoskeletal Problems:	Yes	No
Head Tilt/Face Turn:	Yes	No	Neurological Problems:	Yes	No
Stumbles Over Objects/Clumsy:	Yes	No	Development Delayed:	Yes	No
Poor Motor Control:	Yes	No	Ear/Nose/Throat Problems:	Yes	No
			Head Injury/Trauma:	Yes	No

If yes, please explain:

______________________________________________________________________________________________________________________________________________________

Skills/Milestones

How is your child performing compared to others his/her age:
How well developed is your child's spoken vocabulary?:

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?

______________________________________________________________________________________________________________________________________________________

Skills/Milestones (Under 5)

Gross Motor Activity	Average Age	Your Child
- Rolled Over	3.5 months
- Sits w/out Support	6.5 months
- Walks Unaided/Alone	12 months
- Kicks a Ball	18 months
- Toilet Trained	24 months
- Rides Tricycle	3 years

Fine Motor Activity	Average Age	Your Child
- Reaches/Grasps for Objects	4 months
- Scribbles Spontaneously	15 months
- Stacks/Piles Blocks	18 months
- Eats With a Fork/Spoon	3 years

Language Activity	Average Age	Your Child
- Smiles Spontaneously	1 month
- Says Single Words	12 months
- Refers to Self by First Name	18 months
- Knows Full Name	3 years

______________________________________________________________________________________________________________________________________________________

Developmental History (Under 5)

Length of Pregnancy: Type of Delivery: 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. - oz.

Was child in NICU?: Yes No
If yes, how long was child on oxygen:

Strabismus/Amblyopia

-----Strabismus/Ambylopia History-------------------------------------------------------------------------------------------------------

At what age was the eye turn first noticed?: Did it start suddenly or gradually?:

Which direction does the eye turn? (select 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?

If yes, estimate the results:

Please describe any visual therapy, including duration of treatment, age at which it was started and estimate the results:

Adult History

-----Adult Eye Health History-------------------------------------------------------------------------------------------------------

When was your last eye exam: Where:
Who is your Primary Care Physician:

Do you have any MEDICATION ALLERGIES?

Please list all MEDICATIONS you currently use (including over the counter, eye drops and supplements):

List all EYE SURGERIES or INJURIES:

Have you been diagnosed with any of the following EYE CONDITIONS (check all that apply)?

Blindness	Corneal Dystrophy	Thyroid Eye Disease	Cataract
Eye/Eyelid Cancer	Macular Degeneration	Implant Lens Right Eye	Glaucoma
Retinal Detachment	Implant Lens Left Eye	Hypertensive Retinal Disease	Diabetic Retinal Disease
Dry Eye Syndrome	Amblyopia/Lazy Eye*	Strabismus/Wandering Eye*

*If checked, please complete Strabismus/Ambylopia tab.

Other Eye Conditions:

Check any of the following symptoms you experience:

Eye Pain	Flashes of Light	Change in Distance Vision	Dryness or Burning in Eyes
Light Sensitivity	Change in Near Vision	New Spots or Floaters	Sandy or Gritty Feeling
Fluctuating Vision	Eye Itching	Excess Tearing
Double Vision	Mucus Discharge or Crusted Lids	Loss of Side Vision

Eye Strain with Reading or Computer Work
Dizziness or Car Sickness

Other Eye Symptoms:

VISION HISTORY
What is your primary Vision Correction?

Have you ever worn Contact Lenses? Yes No
Are you interested in Contact Lenses? Yes No
Are you interested in Laser Vision Correction? Yes No

Are your Contact Lenses comfortable and working well for you?
Do you have additional glasses? (back up, reading, computer, sun, music, etc)
What is your primary occupation?
How many hours per day do you work on a computer?
List your hobbies or other activities:

CURRENT GENERAL HEALTH HISTORY
Do any of the following conditions apply to you?

Allergy/Hay Fever	Rheumatoid Arthritis	Herpes Zoster	Asthma	HIV	Skin Rashes
Thyroid Disease	Hepatitis	Sinus Problems	Cancer	Headaches	Seizures
Depression	Migraines	Multiple Sclerosis	High Blood Pressure	Diabetes (Insulin Dependent)	Parkinson's Disease
Low Blood Pressure	Diabetes (Non-Insulin Dependent)	Alzheimer's Disease	Head Injury (Including Whiplash)	High Cholesterol	Stroke

Currently Pregnant
List any other conditions (such as Autism, Down Syndrome, ADD/ADHD, Hearing impaired, Speech impaired, Anxiety disorder etc...)

Do you use any of the following:
Alcohol Tobacco Recreational Drugs

FAMILY HISTORY
Is there a history of any of the following conditions in your immediate family?

Glaucoma	Rheumatoid Arthritis	Diabetes
Retinal Disease	Retinal Detachment	Crossed or Wandering Eye
Macular Degeneration	Albinism	Amblyopia/Lazy Eye

Other Family History of Eye Conditions:

Head Trauma

-----Head Trauma/TBI History-------------------------------------------------------------------------------------------------------

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?

Where you hospitalized?

Describe any previous injuries and dates:

What types of professional care have you received or are receiving due to this injury?

What is your most significant visual concern at this time?

Brain Injury Vision Symptom Survey

*Score such behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4*

Eyesight Clarity
Distance vision blurred and not clear -- even with lenses
Near vision blurred and not clear -- even with lenses
Clarity of vision changes or fluctuates during the day
Poor night vision / can't see well to drive at night

Visual Discomfort
Eye discomfort/sore eyes/eyestrain
Headaches or dizziness after using eyes
Eye fatigue/very tired after using eyes all day
Feel "pulling" around eyes

Doubling
Double vision -- especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading

Light Sensitivity
Normal indoor lighting is uncomfortable
Outdoor light too bright -- have to use sunglasses
Indoors fluorescent light is bothersome or annoying

Dry Eyes
Eyes feel "dry" and sting
"Stare" into space without blinking
Have to rub the eyes a lot

Depth Perception
Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, size, legibility)

Peripheral Vision
Side vision distorted / objects move or change position
What looks straight ahead -- isn't always straight ahead
Avoid crowds / can't tolerate "visually busy" places

Reading
Short attention span / easily distracted when reading
Difficulty / slowness with reading and writing
Poor reading comprehension / can't remember what was read
Confusion of words / skip words when reading
Lose place / have to use finger not to lose place when reading

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

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
		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
		Difficulty concentrating on visual tasks
		Difficulty maintaining eye contact
		One eye turns in, out, up or down
		Flashes of light

What activities can you no longer engage in due to your accident / injury?

Online Patient Form

Demographics

Child History

Strabismus/Amblyopia

Adult History

Head Trauma

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