Online Patient Form

Patient Information

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

Address:
City:		State:	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 TX UT VT VI VA WA WV WI WY	Zip Code:

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
Misc/Guardian

Referral

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?:

Billing Information

Is The Billing Address the Different? Yes

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

Address:
City:		State:	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 TX UT VT VI VA WA WV WI WY	Zip Code:
Home Phone:
Work Phone:

Primary Insurance

Insurance Information

Insurance Name:	None AARP Accounts Management Services Aetna Ameren American Family Mutual Insurance Company American Heritage Life Insurance Company American Republic Corp Insurance Company Anthem Blue Cross Blue Shield Assurant Health BAS/HealthLink Benefit Management, Inc. BJC Healthcare Blue Cross Blue Shield Boilermakers National Care Improvement Plus Carpenters H&W/CMR CBA Cerner HealthPlan Services Champva Christian Brothers Service Cigna Continental Life Insurance CoOportunity Health CoreSource Coventry Health Care Cox Health Systems Insurance Company Custom Network Davis Vision Dr. Timothy D. McGarity, M.D., P.C. Encore Equitable Essence Healthcare EyeMed Vision Care EyeQuest First Health FMH Benefit Services, Inc. FMH/HealthLink GBS GEHA Healthlink Genworth Life Insurance Company GHP Advantra GHP ASO GHP CoventryOne Golden Rule Insurance Company Great-West Healthcare Group Health Plan Guardian Guideone Insurance Billing GWH-CIGNA Health Alliance Health Net HealthChoice Healthe Exchange HealthLink HealthPartners HealthScope Healthsmart Benefit Solutions, INC Horizon BCBSNJ Hospital Services Group HSI Humana Humana Vision Care Plan Indiana Roofers/HealthLink Leslie & Associates Benefit Alliance LifeShield Manhattan Life Medco Medi-Share Medica Insurance Company Medico Insurance Company Medtrak Mercy Health Plan Meritain Health Met Life Mid-West National Life Insurance Co Missouri Care Health Plan MO Health Net MoDOT/MSHP Moyes Eye Center Mutual of Omaha National Vision Administrators, LLC Opticare Prairie States Enterprises, Inc Principal Financial Group Principal Life Insurance PT Employer Restoration Eye Care Security Life Spectera StarMount Life Ins Superior Vision The Mail Handlers Benefit Plan TLC TransAmerica Tricare UMR United Health Care University of Missouri USAA Life Insurance Company Vision Service Plan Welfare Fund of Engineers 513 WMHA WPS Medicare z z-United Healthcare zAARP Health Care Options zAetna Global Benefits zAetna One Tampa zAetna. zAlwaysCare zAnthem zAnthem BCBS zAnthem Blue Preferred Plus zAPWU Health Plan zAR Benefits zAR Health zAssurant Health - 2806 zAssurant Health PHCS zAVMA Group Health & Life Insurance zAVMA Group Health & Life Insurance Tr zBankers Life and Casualty Company zBlue Cross Blue Shield of Illinois zBlueCross BlueShield of Kansas zBlueCross BlueShield of Kansas City zBSBS zCIGNA Health & Life Insurance Company zCigna International zConnecticut General Life Insurance zCoventry zCoventry Health Care Medical zCoventry Healthcare zCoventry National Network zCoventry of Missouri zCross Blue Shield Federal Zenith Administrators Inc Zenith/HL zGolden Rule Insurance Co zHealthlink Open Access II/CBS zHealthSCOPE Benefits, Inc. zHumana zHumana One zMedicare Part B zPrincipal Life Insurance Company zTricare Reserve Select zTricare South Region zUHC - 30557 zUMR zUMR/HL zUnited Healthcare zUnited Healthcare International zUnited Healthcare Vision Claims Depart zUnitedHealthcare zWPS zWPS Health Insurance zzAvesis zzEmpire BlueCross BlueShield zzEyeQuest Vision Insurance zzUHG zzUnited Healthcare zzUnitedHealthcare zzzUnited Healthcare International
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 Insurance

Insurance Information

Insurance Name:	None AARP Accounts Management Services Aetna Ameren American Family Mutual Insurance Company American Heritage Life Insurance Company American Republic Corp Insurance Company Anthem Blue Cross Blue Shield Assurant Health BAS/HealthLink Benefit Management, Inc. BJC Healthcare Blue Cross Blue Shield Boilermakers National Care Improvement Plus Carpenters H&W/CMR CBA Cerner HealthPlan Services Champva Christian Brothers Service Cigna Continental Life Insurance CoOportunity Health CoreSource Coventry Health Care Cox Health Systems Insurance Company Custom Network Davis Vision Dr. Timothy D. McGarity, M.D., P.C. Encore Equitable Essence Healthcare EyeMed Vision Care EyeQuest First Health FMH Benefit Services, Inc. FMH/HealthLink GBS GEHA Healthlink Genworth Life Insurance Company GHP Advantra GHP ASO GHP CoventryOne Golden Rule Insurance Company Great-West Healthcare Group Health Plan Guardian Guideone Insurance Billing GWH-CIGNA Health Alliance Health Net HealthChoice Healthe Exchange HealthLink HealthPartners HealthScope Healthsmart Benefit Solutions, INC Horizon BCBSNJ Hospital Services Group HSI Humana Humana Vision Care Plan Indiana Roofers/HealthLink Leslie & Associates Benefit Alliance LifeShield Manhattan Life Medco Medi-Share Medica Insurance Company Medico Insurance Company Medtrak Mercy Health Plan Meritain Health Met Life Mid-West National Life Insurance Co Missouri Care Health Plan MO Health Net MoDOT/MSHP Moyes Eye Center Mutual of Omaha National Vision Administrators, LLC Opticare Prairie States Enterprises, Inc Principal Financial Group Principal Life Insurance PT Employer Restoration Eye Care Security Life Spectera StarMount Life Ins Superior Vision The Mail Handlers Benefit Plan TLC TransAmerica Tricare UMR United Health Care University of Missouri USAA Life Insurance Company Vision Service Plan Welfare Fund of Engineers 513 WMHA WPS Medicare z z-United Healthcare zAARP Health Care Options zAetna Global Benefits zAetna One Tampa zAetna. zAlwaysCare zAnthem zAnthem BCBS zAnthem Blue Preferred Plus zAPWU Health Plan zAR Benefits zAR Health zAssurant Health - 2806 zAssurant Health PHCS zAVMA Group Health & Life Insurance zAVMA Group Health & Life Insurance Tr zBankers Life and Casualty Company zBlue Cross Blue Shield of Illinois zBlueCross BlueShield of Kansas zBlueCross BlueShield of Kansas City zBSBS zCIGNA Health & Life Insurance Company zCigna International zConnecticut General Life Insurance zCoventry zCoventry Health Care Medical zCoventry Healthcare zCoventry National Network zCoventry of Missouri zCross Blue Shield Federal Zenith Administrators Inc Zenith/HL zGolden Rule Insurance Co zHealthlink Open Access II/CBS zHealthSCOPE Benefits, Inc. zHumana zHumana One zMedicare Part B zPrincipal Life Insurance Company zTricare Reserve Select zTricare South Region zUHC - 30557 zUMR zUMR/HL zUnited Healthcare zUnited Healthcare International zUnited Healthcare Vision Claims Depart zUnitedHealthcare zWPS zWPS Health Insurance zzAvesis zzEmpire BlueCross BlueShield zzEyeQuest Vision Insurance zzUHG zzUnited Healthcare zzUnitedHealthcare zzzUnited Healthcare International
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 / Adult Vision Therapy 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:

_____________________________________________________________________________________________________________________________

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

Event/Condition...Age...Severity...Complications:
Event/Condition...Age...Severity...Complications:
_____________________________________________________________________________________________________________________________

Neuro/Psych eval:	Yes	No	By Whom?
Occupational Therapy eval?	Yes	No	By Whom?

_____________________________________________________________________________________________________________________________

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

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:
Reason for Examination:
Results/Recommendations:

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?:

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	Rereads Same Line

Are there any other complaints your child makes concerning vision?

Do you have any other concerns / observations concerning your child's vision?

Strabismus/Amblyopia

Strabismus/Amblyopia

Strabismus/Ambylopia History (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?:

Does the eye turn more when looking:

Up	To the Right
Down	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:


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:

Brain Injury

Brain Injury - (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 due to your accident/injury?:

Describe any previous injuries and dates:


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


What is your most significant visual concern at this time?

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

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

Reading and Computer Symptom Checklist

Convergence Insufficiency Symptom Survey

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