Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Widowed Divorced Separated	Employer / School Name
Spouse/Guardian		Do you have the following?:	Living Will Power of Attorney

Medical History

Reason for Visit:

Secondary Reasons:

Medications: No Meds Used

Please describe any injuries or surgeries you have had:

Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Primary Care Physician:
Pregnant Or Nursing:	No Yes Unsure Other
Pharmacy:

Do you have any of these medical conditions? If yes, please describe:

	Yes	No
Blurry Vision
Fluctuating Vision
Vision Loss
Distorted Vision
Double Vision
Squinting
Light Sentistive
Dry Eyes
Itchy Eyes
Burning Eye
Gritty/Sandy Eyes

	Yes	No
Flashing Lights
Floaters
Eye Pain
Eye Redness
Headaches
Reading Difficulties
Ocular Fatigue
Balance Difficulty
Frequent Falls
Bumping into Objects

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

	Parent	Sibling	Other	None
Glaucoma
Macular Degen
Retinal Detach
Poor Vision
Cross/Lazy Eye
Diabetes
Hypertension
Heart Disease
Stroke
Cancer

Other:

Review of Systems

Please choose from the menu options or select "OTHER" to type in or your own text. Thank you!

General:	None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other	Ear/Nose/Throat:	None Neck Problems Sinus Problems Sore Throat (Recent) Headache Morning Headaches Migraine Headache Cluster Headache Hearing Loss Tinnitus Congestion Dry throat / mouth Sleep Apnea Other
Skin:	None Acne Lupus Dermatitis Eczema Psoriasis Rosacea Skin Cancer Itching Other	Cardiovascular:	None Congestive Heart Disease Cardiovascular Disease High Cholesterol Hypertension Arrhythmia Heart Murmur Heart Palpitation Chest Pain Arteriosclerosis Coagulation Disorder Mitral Valve Prolapse Low Blood Pressure Other
Respiratory:	None Asthma Cancer: lung Sleep Apnea Sarcoidosis COPD Emphysema Pneumonia Bronchitis Shortness of breath Wheezing Other	Musculoskeletal:	None Arthritis Osteoporosis Fibromyalgia Osteoarthritis Muscular Dystrophy Lupus Decreased range of motion Muscle cramps Pain/tenderness Stiffness Swelling Weakness Other
Psychiatric:	None Attention Deficit Disorder Anxiety Brain Damage (trauma) Panic Attacks Alzheimer's Disease Bi-polar Depression Insomnia Obsessive/Compulsive Paranoia Suicidal Violence Other	Gastrointestinal:	None Acid Reflux Crohn's disease Gastric reflux (GERD) IBS Ulcer Gall bladder problems Jaundice Hepatitis Sarcoidosis Cancer: colon Cancer: Liver Other
Endocrine:	None Crohn's disease Diabetes Type 1 Diabetes Type 2 Diabetes Suspect Hypothyroid Hyperthyroid Gout Hormone Replacement Therapy Other	Blood/Lymph:	None Anemia Hx of Significant Blood Loss Hematologic Disorder Sickle Cell Disorder Breast Carcinoma Lymph Node Disease Temporal Arthritis Cuts slow to clot Easy bruising Other
Neurological:	None Multiple Sclerosis Seizure Disorder Parkinson's Disease Brain Tumor Bells Palsy Dyslexia Headache Balance problems Vertigo Tremors Changes in senses Dementia Memory problems Muscle weakness Numbness, paralysis Personality changes Speech problems Other	Genitourinary:	None Amenorrhea Menopause Impotence Jaundice Uterine Cancer Prostate Cancer Kidney Stones Pregnant Nursing Syphilis Prostate Problems Bladder Infections STD- herpetic STD- chlamydia Other
Immune:	None Seasonal allergies Environmental allergies Food allergies Drug allergies (please specify) Sjogren's syndrome AIDS Herpes Simplex HIV Simplex Mononucleosis Tuberculosis Cytomegalovirus Infection Herpes Zoster Lyme Disease Sarcoidosis Syphilis Hives Itching Mild allergy symptoms Severe allergy symptoms Swelling Other	Eyes:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Developmental	none unknown complicated birth medical complications Other	Other:

Social History

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

STD's:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other
Alcohol Use:	No Yes Occasionally Socially Other
Illegal Drug Use:	No Yes Other

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Decline to Specify

Ethnicity:

African American Asian Caucasian Hispanic or Latino Other Pacific Islander Decline to Specify

Preferred Language:

English Spanish French Japanese Vietnamese Decline to Specify

Vision Therapy

Child History

Child's Full Name:

Child's Preferred Name:

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

______________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY:

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

List significant illnesses, bad falls, high fevers or chronic illnesses:
Event/Condition...Age...Severity...Complications:
Event/Condition...Age...Severity...Complications:
______________________________________________________________________________________________________________________________________________________

Neuro/psych eval: YesNo By Whom?
Occupational Therapy eval? YesNo 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: ______________________________________________________________________________________________________________________________________________________

MED HX / SYSTEM REVIEW:

NOTICE 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 complete strabismus / amblyopia tab.

______________________________________________________________________________________________________________________________________________________
DEVELOPMENTAL HISTORY:

Length of Pregnancy: Type of delivery: Natural Caesarian 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 child 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
Sits w/out support	6.5 months	Early Late Normal Unsure
Walks unaided / alone	12 months	Early Late Normal Unsure
Kicks a ball	18 months	Early Late Normal Unsure
Toilet trained	24 months	Early Late Normal Unsure
Rides tricycle	3 years	Early Late Normal Unsure

FINE MOTOR
ACTIVITY	AVERAGE AGE	YOUR CHILD
Reaches / grasp for object	4 months	Early Late Normal Unsure
Scribbles spontaneously	15 months	Early Late Normal Unsure
Stacks / Piles blocks	18 months	Early Late Normal Unsure
Eats with a fork/spoon	3 years	Early Late Normal Unsure

LANGUAGE
ACTIVITY	AVERAGE AGE	YOUR CHILD
Smiles spontaneously	1 month	Early Late Normal Unsure
Says single words	12 months	Early Late Normal Unsure
Refers to self by first name	18 months	Early Late Normal Unsure
Knows full name	3 years	Early Late Normal Unsure

How is your child performing compared to others his/her age: Above average Average Below average
How well developed is your child's spoken vocabulary? excellent very well developed average behind delayed

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?

______________________________________________________________________________________________________________________________________________________
VISUAL HISTORY:

Main reason for having an examination today:
Date of last evaluation: Doctor's name: Gabby Marshall, OD Amanda Balsalobre, OD Michael Coffman, OD Audrey Brumley, OD
Reason for examination:
Were glasses, contact lenses or other optical devices recommended? Yes No If yes, are they used? Yes No Sometimes If yes, when?
If no, why not?
Results / Recommendations:

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?


______________________________________________________________________________________________________________________________________________________

Strabismus/Amblyopia

(for children and adults with a lazy eye, eye turn or crossed or wandering eye)

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)?
Up Down Out In

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	down
to the right	to the left
up close	in the distance

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:

TBI History

(Stroke, Head injury, Concussion, Whiplash, Motor Vehicle Accident, Bike Accident, Brain Surgery, etc...)

Date of most recent event:

Briefly describe the injury:

What part of the head was affected: Face Top of head Back of head Left side Right side Forehead

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?

(List care such as neurological, psychological, occupational therapy, physical therapy, speech, auditory, chiro, osteopathic, acupuncture, neurofeedback)


What is your most significant visual concern at this time?


####### B I V S S ######### (Brain Injury Vision Symptom Survey) #############################################################

Score each 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 driving at night

VISUAL COMFORT

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
	Dislike heights
	Difficulty understanding what is seen
	Difficulty using both sides of the body together
	Difficulty recognizing words
	Memory problems
	Difficulty recognizing faces
	Difficulty focusing one or both eyes
	Difficulty remembering names of objects
	Frequent squinting or blinking
	Difficulty remembering people's names
	Vision appears unstable or shifts from eye to eye
	Unusual head tilt or turn
	Difficulty with time management
	Portions of a page or objects appear to be missing

Before	After
	Difficulty finding objects when grouped together
	People or things suddenly appear unexpectedly from one side
	Patterned wallpaper or carpets are bothersome
	Awkward or poor balance
	Looking to the side of objects to see them better
	Ears ringing / Tinnitus
	Tunnel vision
	Confusion / Disorientation
	Difficulty concentrating on visual tasks
	Gets lost often
	Difficulty maintaining eye contact
	Bothered by noises
	One eye turns in, out, up or down
	Bothered by touch
	Flashes of light

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

Dry Eye

Over the past week, which of the following eye symptoms have you experienced?

	Glare		Eye ache		Itching
	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?

Reading/Computer

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.
If the patient responds with "yes" please qualify with frequency choices. Do not give examples.

Points: Never =0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4

1. Do your eyes feel tired when reading or doing close work?
2. Do your eyes feel uncomfortable when reading or doing close work?
3. Do you have headaches when reading or doing close work?
4. Do you feel sleepy when reading or doing close work?
5. Do you lose concentration when reading or doing close work?
6. Do you have trouble remembering what you have read?
7. Do you have double vision when reading or doing close work?
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9. Do you feel like you read slowly?
10. Do your eyes ever hurt when reading or doing close work?
11. Do your eyes ever feel sore when reading or doing close work?
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
14. Do you lose your place when reading or doing close work?
15. Do you have to reread the same line of words when reading?

NOTE: For children a score of 16 or more indicates the need for a binocular vision evaluation. For adults a score of 21 does.

In addition:
Check all that apply:

	Reverses or forgets letters, numbers or words
	Tendency to close or cover one eye
	Confuses similar looking words
	Head tilt or movement
	Difficulty recognizing the same word in the next paragraph
	Poor reading comprehension
	Poor spelling
	Head too close to the paper while reading or writing
	Poor visual-motor (eye-hand/foot) coordination
	Difficulty tracking moving objects, balls, etc...

	Confuses right and left
	Writing is crooked or poorly spaced
	Difficulty following a sequence of directions
	Misalignment of digits or columns of numbers
	Whispers when reading silently
	Errors copying from chalkboard, computer or book
	Comprehension decreases over time
	Avoids near work or reading
	Does not visualize
	Difficulty completing assignments in the time allotted

Dizziness/Motion Sensitivity

(Dizziness, Motion Sickness, Car Sickness, etc)
Check all of the symptoms that are significant for you:
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

---

Were you referred to our office? Yes No Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?