General

Patient Information

Title	First	Last	MI	Suffix	Preferred Name
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	FL AK AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV 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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Primary Doctor		Misc/Guardian
Primary Care Doctor		Preferred Language

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

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

Home Phone:
Work Phone:

Vision Ins

Primary

Insurance Name:	None Davis Vision Envolve Vision EyeMed March Vision Care Spectera Eyecare Networks Superior Vision VSP
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision

Secondary

Insurance Name:	None Davis Vision Envolve Vision EyeMed March Vision Care Spectera Eyecare Networks Superior Vision VSP
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Ins

Primary

Insurance Name:	None AARP Medicare Complete AARP Medicare Supplement Aetna AIG Always Care Amerigroup BCBS Medicare Advantage BCBS Of NM CCMSI ChampVA Cigna ConnectYourCare LLC Crownpoint Health Care DVR Esis FCE 1st Health Network First United Health Food Industry Self Insurance Fund GEHA Hartford Health Scope Healthnet Federal SV Humana Independance Indian Tribal Health Insurance Infant See Progam Liberty Mutual Liberty National LifeWise Assurance Company Lions Club Voucher LOP Lovelace Medicare Plan Medicaid Medicare Mediplus Meritain Health 41124 MetLife MindSet Molina MSLA NALC New Mexico Health Connections New Mexico Lions Operation Kidsight New Mexico Mutual Casualty Company NMHC APS Optic Care Presbyterian Health Plan Rocky Mountain Health Plan Saint Paul Travelers Sandia National Labratories Self Pay Shasta State Of New Mexico Dept Of Finance And Administration Summit TransAmerica Premier Life Ins Co Tricare Tricare For Life True Choices True Health UMR 39026 UMR 79480 United Health Care United Of Omaha Life Ins. Co. University Of NM Hospital US Department Of Veterans Affairs USAA Veterans Choice Program Vision Care Direct Web TPA Western Sky Community Care Workers Comp Xerox State Healthcare, LLC York Risk Services Group Zuni Purchased Referred Care
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical

Secondary

Insurance Name:	None AARP Medicare Complete AARP Medicare Supplement Aetna AIG Always Care Amerigroup BCBS Medicare Advantage BCBS Of NM CCMSI ChampVA Cigna ConnectYourCare LLC Crownpoint Health Care DVR Esis EyeMed FCE 1st Health Network First United Health Food Industry Self Insurance Fund GEHA Hartford Health Scope Healthnet Federal SV Humana Independance Indian Tribal Health Insurance Infant See Progam Liberty Mutual Liberty National LifeWise Assurance Company Lions Club Voucher LOP Lovelace Medicare Plan Medicaid Medicare Mediplus Meritain Health 41124 MetLife MindSet Molina MSLA NALC New Mexico Health Connections New Mexico Lions Operation Kidsight New Mexico Mutual Casualty Company NMHC APS Optic Care Presbyterian Health Plan Rocky Mountain Health Plan Saint Paul Travelers Sandia National Labratories Self Pay Shasta State Of New Mexico Dept Of Finance And Administration Summit Superior Vision TransAmerica Premier Life Ins Co Tricare Tricare For Life True Choices True Health UMR 39026 UMR 79480 United Health Care United Of Omaha Life Ins. Co. University Of NM Hospital US Department Of Veterans Affairs USAA Veterans Choice Program Vision Care Direct Web TPA Western Sky Community Care Workers Comp Xerox State Healthcare, LLC York Risk Services Group Zuni Purchased Referred Care
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Child History

PLEASE COMPLETE THIS SECTION IF THE APPOINTMENT IS 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:

Main reason for having an examination today: When did it start?
How often does it happen? How long does it last? What do you do, if anything, to improve symptoms?
Date of last evaluation: Doctor's name:

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:
______________________________________________________________________________________________________________________________________________________
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:

Other Allergies:


Have you, your child's teacher, babysitter, or other guardians noticed, or has your child complained of:

Headaches	Blurred Vision	Double Vision	Eyes 'Hurt' or are 'Tired'
Eyes Itch	Eyes Burn	Eyes Tear	Eyes Frequently Red
Frequent Styes	Bothered By Light	Loses Attention Easily	Motion / Car Sickness
Closing / Covering One Eye	Loses Place When Reading	Nausea When Copmleting Visual Tasks
Poor Reading Comprehension	When Reading, Letters / Words Appear To Move / Float	Dizziness, 'Spinning' Sensation or Unbalance

Did these issues resolve? No Yes If yes, was it on it's own or by doctor intervention

______________________________________________________________________________________________________________________________________________________

Child has been diagnosed with:	Yes / No	Status	When was the last instance if not current or chronic?
Allergies / Hay Fever	Yes No	Current
Behavioral Problems	Yes No	Current
Blood Disorder / Low Iron	Yes No	Current
Cancer	Yes No	Current
Depression	Yes No	Current
Developmental Problems	Yes No	Current
Diabetes (Insulin)	Yes No	Current
Diabetes (Non-Insulin)	Yes No	Current
Ear Infections	Yes No	Current
Head Injury / Trauma*	Yes No	Current
Heart Disease	Yes No	Current
Hepatitis	Yes No	Current
Herpes Zoster	Yes No	Current
High Blood Pressure	Yes No	Current
High Cholesterol	Yes No	Current
HIV	Yes No	Current
Low Blood Pressure	Yes No	Current
Lung Problems / Asthma	Yes No	Current
Multiple Sclerosis	Yes No	Current
Musculoskeletal Problems	Yes No	Current
Neurological Problems*	Yes No	Current
Seizures*	Yes No	Current
Sinus	Yes No	Current
Skin Rashes	Yes No	Current
Stroke*	Yes No	Current
Surgery / Hospitalizations*	Yes No	Current
Thyroid Disease	Yes No	Current
Tinnitus	Yes No	Current
Other	Yes No	Current
Other	Yes No	Current

Please use the space below to expand on any items marked yes above providing additional information such as complications that ocurred, severity of the illness or incident, what type of sugery, what bones were broken, and any other information that provides a more specific and detailed picture of your child's medical background. Please include events such as bad falls, high fevers, significant illness, even if they seem common


IF ANY OF THE STARRED ITEMS ARE MARKED YES, OR ANY OTHER SITUATION INVOLVING THE HEAD AND / OR SPINE, PLEASE FILL OUT THE HEAD TRAUMA TAB

______________________________________________________________________________________________________________________________________________________

Family History:

Family medical history is any important part of anyone's examination. Many disease and chronic conditions have genetic component. A knowledge of the family medical history can help spot possible issues early.
Family medical history is unknown due to a circumstance such as adoption

Disease / Condition / Illness	Specific Type	Is there a family history?	If so, what is the relationship to the child?
Poor Vision
Strabismus
Amblyopia
Blindness
Neurological
Learning Issues
Autoimmune Disease
Heart Disease
Blood Disorders / Low Iron
Diabetes
Seizures
Cancer
Other

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 birth weight:lbs. and oz.
Apgar score:@ birth after 10 minutes
My child is:
biological
adopted      At what age?
foster
other      Explain:

______________________________________________________________________________________________________________________________________________________
SKILLS / MILESTONES:

Did your child creep?(Stomach on floor)

If yes, what age?

Crawl?

If yes, age?

All fours?

If not, please discribe:

The following activities have listed the average age for these milestones to be reached. Please use the drop down menu to select if the child reached these milestones early, average, late or if you are unsure when. Please remember these milestones can be reached dureing a wide range of time and the average is just somewhere in the middle of the range, being off of average is not an indicator of a problem on its own so please answer honestly.

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

First words at age: Was early speech clear to others? No Yes Is it clear now? No Yes
How is your child performing compared to others his/her age: Above average Average Below average

First words at age?

Was speech clear to others?

Is it clear now?

How well developed is your child's spoken vocabulary? excellent very well developed average behind delayed

How much time does your child spend looking at a compute ror other electronic device?

Does your child have behavior issues?

Has your child undergone any of the following testing/treatment/therapy?

Educational:		Neurological:		Psychological:
Occupational:		Speech / Auditory:		Physical:

If yes, please list all previous evaluations done on your child:

Describe any previous injuries and dates:


______________________________________________________________________________________________________________________________________________________

CURRENT STATUS

CONSTITUTIONAL:
Has your child had any issues with blood pressure, reacing heart, or feeling their pulse 'pounding'? No Yes
Has your child had any issues with their breathing? No Yes
Has your child had any fevers recently? No Yes If yes, what was the highest reading? No Yes
Has your child had any unexplained weight changes? No Yes
______________________________________________________________________________________________________________________________________________________

OPHTHALMOLOGIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Eye turns in or out	Squints and/or blinks a lot	Lacks interest in looking at objects
Rubs eyes excessively	Covers or closes one eye often	Reddened or encrusted eyelids
Eyelid Droops	Tilting head and/or turning face	Poor tracking or eye movements
Poor Motor Control	Eyes hurt or tired	Stumbles over objects or is clumsy
Headaches	Blurred Vision	Nausea when doing visual tasks
Double Vision	Visible Stye	Motion or car sickness
Watery Eyes	Eyes feel dry, gritty, or 'burn'	Difficulty or extreme dislike for reading

Has your child had any other complaints about their vision?
Have you, their teacher /babysitter / guardian noticed anything else concerning their vision?

	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		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?
Have you ever been prescribed RESTASIS eye drops?

______________________________________________________________________________________________________________________________________________________

OTOLARYNGOLOGIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Feeling off balance	Feeling dizzy	Feeling like they've been spinning
Excessive Clumsiness	Trouble Hearing	Sound hurts ears
Ears feel full	Nose feels full	Pain behind eyebrows / deep in ears

______________________________________________________________________________________________________________________________________________________

RESPIRATORY:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Trouble catching breath - no activity	Trouble catching breath post-active	Trouble holding breath
Feeling of not getting enough air	Hyperventilating

______________________________________________________________________________________________________________________________________________________

GASTROINTESTINAL:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Nausea	Stomach Pain	Vomiting
Diarrhea	Constipation	Feeling of food being stuck

______________________________________________________________________________________________________________________________________________________

MUSCULOSKELETAL:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Legs seem unsteady	Trouble extending leg fully	Repeated twists of ankle
Knee / Hip pain	Sitting hurts at times	Trouble bending at waist
Pain in arms / wrists / shoulders	Trouble reaching high	Abnormal posture

has your child recently had a growth spurt? No Yes
______________________________________________________________________________________________________________________________________________________

INTEGUMENTARY:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Rashes	Easily bruise	Loose skin
Excessibly dry / flaky skin	Feeling of bugs or skin	Unexplained changes in skin color

______________________________________________________________________________________________________________________________________________________

NEUROLOGICAL:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Seizures	Abnormal sleep cycle	Fainting
Difficulty focusing / 'Daydreaming'	Sudden change in coordination	Change in speech (ie. slurring)
Smells scents not present	Tingling (aka Pins Needles)	Numbness of body parts

______________________________________________________________________________________________________________________________________________________

PSYCHIATRIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Excessive fears	Anxious / Nervous	Guiliting feelings (lots of 'Sorry')
Extreme mood swings	Withdrawl from friend group	Withdrawl from hobbies
Hallucinations	Major change in eating habits	Excessive anger / violence

______________________________________________________________________________________________________________________________________________________

HEMATOLOGIC / LYMPHATIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:

Bleeds excessively / Doesn't clot	Wounds don't heal or heal slowly	Excessive nosebleeds
Excessive bleeding from gums	Swollen lymph nodes	Recurring infections

______________________________________________________________________________________________________________________________________________________

Current grade in school: School:
What is their favorite subject?
Current special services: Prior special services: Age started kindergarten: Does your child like school?

In school work: Above averageAverageBelow average

Is your child working up to his/her potential?
Your feeling: Teacher's feeling:

What subjects are easy for your child?
What subjects are hard for your child?
Does your child like to read? Voluntarily? What types of books?
Has your child repeated a grade? If so, when?
Has your child changed schools often? If yes, when?
Does your child have behavior problems at school? If yes, describe:

As part of the vision screening, we need to know how your child is doing in school. Please check the areas that apply to you child.

Averge reader

Slow/Fast reader

Dosen't enjoy reading

Perfers to be read to

Poor reading comprehension

Poor writing skills

Poor handwriting skills

Has letter/number reversals

Homework takes longer than it should

Struggles in school

Short attention span

Inconsistent or poor spots performance

Fine or gross motor skill difficulties

Avoids tasks that involve reading

Displays awkwardness and/or clumsiness

Confuses similar looking works

Misaligns numbers

Writes up or down on a slant

Complains of blurred vision

Needs to move when reading

Significant drop in grades in one year

Told that he or she has learning disability

Has headaches, nausea, or dizziness when reading

Honors curriculum

Regular classroom

Special education

Resource room

Tutor

Title 1 reading

Fatigued, frustraded, or stressed

Omits, inserts, or rereads letters and words

Has difficulty copying from the board

Nausea when doing close work

Difficulty spelling

Knocks over objects on a table

Other:

______________________________________________________________________________________________________________________________________________________

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?

Adult History

IF THIS APPOINTMENT IS FOR YOUR CHILD, YOU DO NOT NEED TO FILL OUT THIS TAB

Main reason for having an examination today: When did it start?
How often does it happen? How long does it last? What do you do, if anything, to improve symptoms?
Results / Recommendations:
When was your last eye exam: Where: Reason for examination:
Were glasses, contact lenses or other optical devices recommended? If yes, are they used? If yes, when? If no, why not?
Who is your Primary Care Physician:

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

Allergies to Medications:

Other Allergies:

List all EYE SURGERIES or INJURIES:

Please list any major suregeries you have had that aren't listed above:


VISION HISTORY
What is your primary type of vision correction? Glasses Contact Lenses Laser None
Have you ever worn Contact Lenses? Are you interested in Contact Lenses? Are you interested in Laser Vision Correction?
If yes, please bring your current prescription information with you

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:

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 ** if yes, complete strabismus / amblyopia tab		Strabismus / Wandering Eye ** if yes, complete strabismus tab

Other Eye Conditions:


______________________________________________________________________________________________________________________________________________________

SOCIAL HISTORY

How many hours per day do you work on a computer?

Do you drink alcohol? No Yes How often? Daily Weekly Monthly Few times a year Yearly

Do you smoke? No Yes How often do you go through an entire pack? Daily Weekly Monthly

Do you use recreational drugs? No Yes How often do you use? Daily Weekly Monthly Yearly

Do you hold religious beliefs that may dictate treatment? No Yes

Do you participate in any community groups? (ie. Scouts, Lodges, Lions Club, etc.) No Yes

What are your hobbies?

______________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY

Have you had a Neurological or Psychological evaluation? No Yes

Check here if currently pregnant.    How far along?

Do any of the following conditions apply to you?

Condition	Yes / No	Status	When was the last instance if not current or chronic?
Allergies / Hay Fever	Yes No	Current
Alzheimer's Disease	Yes No	Current
Blood Disorder / Low Iron	Yes No	Current
Cancer	Yes No	Current
Depression	Yes No	Current
Diabetes (Insulin)	Yes No	Current
Diabetes (Non - Insulin)	Yes No	Current
Head Injury / Trauma*	Yes No	Current
Hearing Problems	Yes No	Current
Heart Disease	Yes No	Current
Hepatitis	Yes No	Current
Herpes Zoster	Yes No	Current
High Blood Pressure	Yes No	Current
High Cholesterol	Yes No	Current
HIV	Yes No	Current
Low Blood Pressure	Yes No	Current
Lung Problems / Asthma	Yes No	Current
Multiple Sclerosis	Yes No	Current
Musculoskeletal Problems*	Yes No	Current
Neurological Problems*	Yes No	Current
Parkinson's Disease	Yes No	Current
Rheumatoid Arthritis	Yes No	Current
Seizures*	Yes No	Current
Sinus	Yes No	Current
Skin Rashes	Yes No	Current
Stroke*	Yes No	Current
Thyroid Disease	Yes No	Current
Tinnitus	Yes No	Current
Other	Yes No	Current

Please use the space below to expand on any items marked yes above providing additional information such as complications that occurred, severity of the illness or incident. Please include events such as bad fails, high fevers, significant illnesses, any broken bones or minor surgeries?


IF ANY OF THE STARRED ITEMS ARE MARKED YES, OR ANY OTHER SITUATION INVOLVING THE HEAD AND/OR SPINE, PLEASE FILL OUT THE HEAD TRAUMA TAB.

______________________________________________________________________________________________________________________________________________________

CONSTITUTIONAL:CURRENT STATUS

Have you had any issues with your blood pressure or elevated resting heart rate? No Yes

Have you had any issues with your breathing? No Yes

Have you had a fever recently? No Yes What was the highest reading?

Have you had any unexplained weight changes? No Yes

______________________________________________________________________________________________________________________________________________________

OPHTHALMOLOGIC:

Please check any of the following eye symptoms you are experiencing:

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	Other:

When you are reading or doing computer work do you experience eye strain? IF YES COPMLETE THE 'READING' TAB

Do you experience dizziness or motion sickness? IF YES PLEASE COMPLETE THE 'SYMPTOMS' TAB

The following relate specifically to a history of dry eye. Please mark any of these symptoms that you have experienced within the past week:

Glare	Eye Ache	Itching	Redness	Burning
Light Sensitivity	Stinging	Grittiness	Dryness	Dry Mouth

Tearing / Watery Eyes	Mattering on your eyelids when you wake up in the morning
Night Driving Problems	Eyelids swollen or red along the lash margin
Burning in the morning	Artificial tear drops help, but do not last long enough
Decreased contact lens wearing time

do you take Omega-3 supplements daily? No Yes

Do you use Visine or other 'get the red out' drops? No Yes

Have you ever been prescribed RESTASIS eye drops? No Yes

Do you have any other complaints about your vision?

______________________________________________________________________________________________________________________________________________________

OTOLARYNGOLOGIC:

Are you experiencing any of the following ear, nose, and throat symptoms?

Feeling off balance	Dizziness / Vertigo	Excessive Clumsiness	Trouble Hearing
Sensitivity to sounds	Ears feel full / Muffled	Sinuses / Nose feels full	Pain behind eyes
Dry throat / mouth	Post nasal drip	Feeling like room is wobbling

______________________________________________________________________________________________________________________________________________________

CARDIOVASCULAR:

Are you experiencing any of the following heart related symptoms?

Heartburn

Palpitations

Feeling pulse throbbing

Where?

______________________________________________________________________________________________________________________________________________________

RESPIRATORY:

Are you experiencing any of the following lung related problems?

Trouble catching breath - no activity	Trouble catching breath post - active	Touble holding breath
Feeling of not getting enough air	Hyperventilating	Pain in chest with breathing

______________________________________________________________________________________________________________________________________________________

GASTROINTESTINAL:

Are you experiencing any of the following stomach related symptoms?

Nausea	Stomach Pain	Vomiting
Diarrhea	Constipation	Feeling of food being stuck

______________________________________________________________________________________________________________________________________________________

MUSCULOSKELETAL:

Are you experiencing any of the following muscle and joint symptoms?

Legs seem unsteady	Trouble extending leg fully	Repeated twists of ankle
Knee / hip pain	Sitting hurts at times	Trouble bending at waist
Pain in arms / wrists / shoulders	Trouble reaching high	Abnormal posture

______________________________________________________________________________________________________________________________________________________

INTEGUMENTARY:

Are you experiencing any of the following skin symptoms?

Rashes	Easily bruises	Loose Skin
Excessively dry / Flaky skin	Feeling of bugs on skin	Unexplained changes in skin color
New moles / Marks on skin	Unexplained bumps / Raised skin	Unexplained change in skin texture

______________________________________________________________________________________________________________________________________________________

NEUROLOGICAL:

Are you experiencing any of the following symptoms?

Seizures	Abnormal sleep cycle	Fainting
Difficulty focusing / 'Daydreaming'	Memory lapses	Sudden change in coordination
Change in speach (ie. Slurring)	Smells scents not present	Fatigue
Tingling (aka Pins Needles)	Where?	Numbness of body parts	Where?

______________________________________________________________________________________________________________________________________________________

PSYCHIATRIC:

Are you experiencing any of the following symptoms?

Excessive Fears	Anxious / Nervous	Guilt / Blame self for problems
Extreme mood swings	Withdrawal from friends / Society	Lack of interest in hobbies
Hallucinations	Change in appetite / Eating habits	Excessive anger / Violence
Lack of motivation for common tasks	Paranoia	Obsessive Thoughts

Have you experienced a traumatic event? No Yes When?
Briefly explain what happened? (ie. Loss of loved one, accident, close call, etc.)
Have you been diagnosed with PTSD? No Yes

______________________________________________________________________________________________________________________________________________________

HEMATOLOGIC / LYMPHATIC:

Are you experiencing any of the following symptoms?

Bleeds excessively / Doesn't clot	Wounds don't heal or heal slowly	Excessive nosebleeds
Excessive bleeding from gums	Swollen lymph nodes	Recurring infections

Lazy Eye

PLEASE ONLY COMPLETE THIS SECTION IF THE APPOINTMENT IS FOR LAZY EYE, EYE TURN, CROSSED OR WANDERING EYE

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:

Symptoms

COMPLETE THIS SECTION IF THE PATIENT HAS HAD ANY OF THE FOLLOWING INJURIES:

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 Neck

Was there loss of consciousness? For how long?
When did you first see a doctor regarding your accident/injury?
Were you hospitalized?

DESCRIBE ANY PREVIOUS INJURIES:

Date: Description:
Date: Description:
Date: Description:
Date: Description:
Date: Description:

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?


Brain Injury Vision Symptom Survey
Score each behavior:
Never=0 Mild=1 High Mild=2 Moderate=3 High Moderate=4 Severe=5 High Severe=6

Headache	0 1 2 3 4 5 6
Nausea	0 1 2 3 4 5 6
Vomiting	0 1 2 3 4 5 6
Balance Problems	0 1 2 3 4 5 6

Nervous and Anxious	0 1 2 3 4 5 6
Feeling More Emotional	0 1 2 3 4 5 6
Numbness or Tingling	0 1 2 3 4 5 6

Dizziness (spinning or movement sensation)	0 1 2 3 4 5 6
Lightheadedness	0 1 2 3 4 5 6
Fatigue	0 1 2 3 4 5 6
Trouble Falling Asleep	0 1 2 3 4 5 6

Feeling Slowed Down	0 1 2 3 4 5 6
Feeling Like "in a fog"	0 1 2 3 4 5 6
Difficulty Concentrating	0 1 2 3 4 5 6

Sleeping More Than Usual	0 1 2 3 4 5 6
Drowsiness	0 1 2 3 4 5 6
Sensitivity To Light	0 1 2 3 4 5 6

Difficulty Remembering	0 1 2 3 4 5 6
Visual Problems	0 1 2 3 4 5 6
Slow Wavy Dizziness	0 1 2 3 4 5 6

Sensitivity To Noise	0 1 2 3 4 5 6
Irritability	0 1 2 3 4 5 6
Sadness and Hopelessness	0 1 2 3 4 5 6

Reminating Thoughts	0 1 2 3 4 5 6
Difficulty In Math, Science, Reading	0 1 2 3 4 5 6
Symptoms Worse At The End Of The Day	0 1 2 3 4 5 6
Difficulty With Attention	0 1 2 3 4 5 6
Difficulty Finding Words	0 1 2 3 4 5 6

Were there any symptoms existing prior to injury? if so, please list them:

Yes	No
	Do busy environments cause you to have a headache, feel groggy, dizzy, anxious, tired? Ex: Lunchroom, grocery stores, hallways, etc.
	Do you become dizzy when looking up/down, turning head, walking down busy hallways?
	Do quick movement make you dizzy, anxious, foggy?
	Do your symptoms worsen while traveling in the car?
	Do you have blurred or fuzzy vision while reading?
	Personal or family history of lazy eye or other ocular issues?
	Do you feel frontal pressure in your head/ behind your eyes when engaged in reading/ computer work/ note taking?
	Do you experience blurry or fuzzy vision while reading or have difficulty reading?
	Are you having difficulties with "focus" or trouble with adjusting your eyes from near to far vision?
	Do you feel your performance at school or work changed?
	Ears ringing / Tinnitus
	Are your symptoms worse during the week verses the weekend?
	Are you excessively tired at the end of the day?
	Bothered by noises
	Do your difficulty turning off your thoughts?
Yes	No
	Do you become symptomatic when thinking about your symptoms?
	Have your social activities been restricted?
	Do you have difficulty falling asleep at night or other issues with sleep?
	Personal history of migraines?
	Do headaches occur w/ poor sleep?
	Are headaches more likely to occur at the beginning of the week?
	Does vision appear unstable or shift from eye to eye?
	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
	Have you any neck pain or a history of neck injuries?
	Have you had any symptoms that increase with change in neck position (static or dynamic)?
	Have you experience any visual changes?
	Have you had any episodes of dizziness or disequilibrium?
	What activities can you no longer engage in due to your accident / injury?

Reading

CONVERGENCE IN SUFFICIENCY SYMPTOM SURVEY (CISS)

Please answer the following questions about how your eyes feel when reading or doing close work.
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 (not very often)=1 Sometimes=2 Fairly Often=3 Always=4

1. Do your eye feel tired when reading or doing close work?	0 1 2 3 4
2. Do your eyes feel uncomfortable when reading or doing close work?	0 1 2 3 4
3. Do you have headaches when reading or doing close work?	0 1 2 3 4
4. Do you feel sleepy when reading or doing close work?	0 1 2 3 4
5. Do you lose concentration when reading or doing close work?	0 1 2 3 4
6. Do you have trouble remembering what you have read?	0 1 2 3 4
7. Do you have double vision when reading or doing close work?	0 1 2 3 4
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?	0 1 2 3 4
9. Do you feel like you read slowly?	0 1 2 3 4
10. Do your eyes ever hurt when reading or doing close work?	0 1 2 3 4
11. Do your eyes ever feel sore when reading or doing close work?	0 1 2 3 4
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?	0 1 2 3 4
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?	0 1 2 3 4
14. Do you lose your place when reading or doing close work?	0 1 2 3 4
15. Do you have to reread the same line of words when reading?	0 1 2 3 4

In addition: Check all that apply

Tendency to close or cover one eye	Reverses or forgets letters, numbers or words
Head tilt or movement	Confuses similar looking words
Poor reading comprehension	Difficulty recognizing the same word in the next paragraph
Head too close to the paper while reading or writing	Poor spelling
Difficulty tracking moving objects, balls, etc...	Poor visual-motor (eye-hand/foot) coordination
Writing is crooked or poorly spaced	Confuses right and left
Misalignment of digits or columns of numbers	Difficulty following a sequence of directions
Errors copying from chalkboard, computer or book	Whispers when reading silently
Avoids near work or reading	Comprehension decreases over time
Difficulty completing assignments in the time allotted	Does not visualize

Dizziness and Motion Sensitivity Checklist

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

Submit Data

Please note that your health history is not reviewed until the day of the appointment.
If you have concerns that you feel require immediate attention, such as floaters, flashes, redness, or loss of vision please call 505-341-2020, extension 3 to schedule an emergency appointment.

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