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:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
Email		Pronoun	he/him/his she/her/hers they/them/theirs
Occupation
Birth 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 Same? 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:

Medical History

Eye History

Reason for Visit:

Primary Reasons:	Secondary Reasons:

Do you currently have any of these symptoms?:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Do you take any of these eye medications?:	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Have you had any eye surgeries? Please describe:

Last Eye Exam:

1 year 2 years 3 years Other

Last Appointment Type

By Doctor:

Primary Vision Correction:

None Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

No Yes Other

Want backup sunglasses?:

No Yes Other

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Medical History

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other

Reason:

Check up Annual Specific Other

Pregnant Or Nursing:

Yes No Unsure Other

Do you have any of these medical conditions?:

Diabetes:	No Yes	Year Diagnosed:
High Blood Pressure:	No Yes
High Cholesterol:	No Yes
Thyroid Conditions:	No Yes
Heart Conditions:	No Yes
Cancer:	No Yes

Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?:

High Blood Pressure:	No Parents Siblings Grandparent Other	Diabetes:	No Parents Siblings Grandparent Other
Thyroid Conditions:	No Parents Siblings Grandparent Other	High Cholesterol:	No Parents Siblings Grandparent Other
Heart Conditions:	No Parents Siblings Grandparent Other	Other:
Cancer:	No Parents Siblings Grandparent Other

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other	Blindness:	No Parents Siblings Grandparent Other

Review of Systems

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

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

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	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long

Race:

White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language:

English French German Spanish Other

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:

_____________________________________________________________________________________________________________________________

Pediatrician's Name: Date of last visit:

is your child especially afraid of doctors?: Yes No    is your child generally healthy? YesNo

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.

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

Skills/Milestones

Does your child have delays in gross motor development?:	Yes No
Does your child have delays in fine motor development?:	Yes No
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
Is your child performing up to their potential?:	Yes No

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?

Eye Turns In/Out	Squints/Blinks a lot
Covers/Closes One Eye	Lacks Interest In Looking At Objects
Rubs Eyes Excessively	Reddened Or Encrusted Eyelids
Eylid Droops	Eye Injury Or Surgery
Patching	Lazy Eye/Amblyopia
Vision Therapy/Orthoptics

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:

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

Brain Injury

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?

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