Adult Extended Questionnaire Please fill out this questionnaire carefullyAppointment: Day Appointment: Date MM slash DD slash YYYY Appointment: Time Hours : Minutes AM PM Patient’s Name First Last GENERAL INFORMATIONFull Name(Required) First Last Untitled Male Female Birth Date MM slash DD slash YYYY AgeHome Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneEmail(Required) Marital status Single Married Divorced Widowed Were you referred to our office? Yes No If yes, whom may we thank for this referral? PhoneAddress Do you have Major Medical Insurance? Yes No If yes, who is the carrier? Policy # Does the insurance cover eye examinations or glasses? Yes No Name of Insured Social Security NumberDriver’s License No What is your occupation? Employer Business Address Spouse’s Name First Last Occupation Spouse’s Employer Business Address MEDICAL HISTORYIs there any Patient history of the following? (please check if there is a history) Diabetes Blindness Eye Turn Glaucoma Cancer Multiple Sclerosis Brain Tumor High Blood Pressure Eye Infections Thyroid Condition Eye Surgery Cataracts Lazy Eye Eye Disease Diabetes Blindness Eye Turn Glaucoma Cancer Multiple Sclerosis Brain Tumor High Blood Pressure Eye Infections Thyroid Condition Eye Surgery Cataracts Lazy Eye Eye Disease Physician’s Name Date of Last Evaluation MM slash DD slash YYYY For what problem / condition? Results and recommendations Medications currently using including vitamins and supplements For what condition(s)? Are you allergic to any foods or medications? Yes No please list Add RemoveCurrent state of health (explain): Any history in your family of an eye turn resulting from a disease or other condition? Yes No If yes, please explain Was there any related trauma, disease, or condition that preceded or accompanied the onset of the eye turn? Yes No If yes, please explain Are you prone to infections? Yes No Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No If yes, please list Add RemoveList illnesses, bad falls, high fevers, ear infections, etcAgeSevereMildComplications Add RemoveHas a neurological evaluation been performed? Yes No By whom? Results Has a psychological evaluation been performed? Yes No By whom? Results Has an occupational therapy evaluation been performed? Yes No By whom? Results DEVELOPMENTAL HISTORYFull-term pregnancy? Yes No Did the mother experience any problems during the pregnancy? Yes No If yes, explain Normal birth? Yes No If No, explain Were forceps used? Yes No Any complications before, during or immediately following delivery? Yes No If yes, explain Were there ever any concerns regarding growth or development? Yes No If yes, explain NUTRITIONAL INFORMATIONCurrent Diet Excellent Good Fair Poor Do you (like /crave) like crave - sweets? Yes No Are there any indications that you have been exposed to any toxic substances or fumes? Yes No If so, explain VISUAL HISTORYAt what age was it first noticed or suspected that it was an eye turn? Did the eye begin turning suddenly or gradually? Does the eye turn (check all that apply) in out up down Is the eye turn getting worse worse better no change Is it always the same eye that turns? Yes No If yes, which eye? Right Left Is the eye turn always present? Yes No If not, under what conditions is it present? Does the eye always turn the same amount? Yes No If no, explain Do you notice if the eye turns more when you look up close? in the distance? to your left? to your right? up? down? Does one pupil ever appear to be larger than the other? Yes No If yes, when? Do you ever notice one or both eyes shaking rapidly? Yes No If yes, when? Do you experience any of the following Yes No If yes, when? Do you experience any of the following Yes No If yes, when? Headaches Yes No If yes, when? Blurred vision Yes No If yes, when? Double vision Yes No If yes, when? Eyes tired Yes No If yes, when? Eyes hurt Yes No If yes, when? Motion sickness / car sickness Yes No If yes, when? Frequent styes Yes No If yes, when? Red or bloodshot eyes Yes No If yes, when? Watery eyes Yes No If yes, when? Bothered by light Yes No If yes, when? Closing or covering an eye to see better Yes No If yes, when? Need to hold paper close when reading or writing Yes No If yes, when? Head tilt Yes No If yes, when? Confusion of letters or words Yes No If yes, when? Skipping or omitting words Yes No If yes, when? Loss of place when reading Yes No If yes, when? Need to use finger to keep place Yes No If yes, when? Poor reading comprehension Yes No If yes, when? Comprehension decreases over time Yes No If yes, when? Write or print poorly Yes No If yes, when? Fatigue easily Yes No If yes, when? Difficulty with short term memory Yes No If yes, when? Difficulty with long term memory Yes No If yes, when? Short attention span / loss of interest Yes No If yes, when? Difficulty attending to details Yes No If yes, when? Poor / awkward general motor coordination Yes No If yes, when? Poor fine motor coordination Yes No If yes, when? Difficulty judging distances Yes No If yes, when? Difficulty driving Yes No If yes, when? Dislike / avoid sports Yes No If yes, when? Difficulty hitting or judging moving targets during sports Yes No If yes, when? List any other complaints you have concerning vision Add RemoveDo you feel your vision hinders your daily activities in any way? Yes No If yes, explain Do you feel your vision limits your potential in any way? Yes No If yes, explain PREVIOUS TREATMENTSHave you had a previous visual evaluation Yes No If yes, Doctor’s Name Date of last evaluation MM slash DD slash YYYY Results and recommendations Were glasses, contact lenses, or other optical devices recommended or prescribed? Yes No If yes, bifocal? single vision? contact lenses? Other Are they worn? Yes No If yes, when? If no, why not? Does the eye turn less when the prescription is worn? Yes No Unsure Have you been told that you have amblyopia (lazy eye)? Yes No Has there been any treatment using an eye patch? Yes No If yes, please describe when the patching was started, how the patching was done, including the age it started, the eye patched, the duration of treatment, and an estimate of the resultsHas there been any surgical treatment? Yes No If yes, please describe the surgery, including the age surgery was performed, the number of operations, the eye(s) operated on, and an estimate of the cosmetic and subjective resultsWas the surgeon satisfied with the results of surgery? Yes No Explain Were you satisfied with the results of surgery? Yes No Explain Have surgical results been maintained? Yes No Explain Has there been any visual therapy? Yes No If yes, Doctor’s name Please describe the type of visual therapy, including duration, the age at which it started and an estimate of resultsAre you here for a second opinion regarding surgery or other treatment? Yes No EMPLOYMENT OR SCHOOLCurrent position Major course of study How many hours daily do you spend at a desk? How many hours daily do you spend reading or studying? How many hours daily do you spend working at near distances? Are you achieving your potential in work or school? Yes No Do you feel you are getting adequate return for the amount of effort you put into a task? Yes No Does your work or course of study demand comprehension from the written word? Yes No Describe briefly your daily activities at work or in schoolHOBBIES/LEISURE TIMEDescribe the types of activities that comprise the majority of your spare timeDo you watch TV? Yes No If yes, how many hours per day?How many days per week?Are you seriously involved with athletics? Yes No Do you feel you are achieving up to your potential in athletics? Yes No Of all the sports you have played:List the ones in which you excel Add RemoveList the ones in which you do poorly / avoid Add RemoveDo you feel your vision limits or prevents you from participating in any activities? Yes No If so, explain what and how Is there any other information that you feel would be helpful / important in our evaluation and/or treatment? Yes No If yes, explain Release Of Information and Insurance FilingIt is often beneficial for us to discuss examination results and to exchange information with other professionals involved in your care. Please sign below to authorize this exchange of information.(Required) I authorize the release of medical information to other health care providers or insurance carriers upon their written request, or upon the recommendation of Vision Source Specialists/Performance Vision Training Center when it is necessary for the treatment of my visual condition or for the processing of insurance claims. This authorization shall be considered valid for the duration of my treatment.Signature of patient or authorized representative(Required)Date MM slash DD slash YYYY Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us to perform a more comprehensive evaluation and to better meet your specific visual needs. If at any time you have any questions or concerns regarding your vision or treatment, please do not hesitate to contact us. You may leave a message for us 24 hours a day / 7 days a week. We request a minimum of 24 hours notice if you are unable to keep this appointment. Please be on time for your evaluation so that we may have the maximum opportunity to evaluate your visual status. Thank you. Sincerely, Dr. Jared Pearson, O.D.