Please fill out this questionnaire carefully

Appointment: Day

Appointment: Date

Appointment: Time

Patient’s Name

First Last

GENERAL INFORMATION

Full Name(Required)

First Last

Untitled

Male

Female

Birth Date

Age

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Email(Required)

Marital status

Single

Married

Divorced

Widowed

Were you referred to our office?

Yes

If yes, whom may we thank for this referral?

Phone

Address

Do you have Major Medical Insurance?

Yes

If yes, who is the carrier?

Policy #

Does the insurance cover eye examinations or glasses?

Yes

Name of Insured

Social Security Number

Driver’s License No

What is your occupation?

Employer

Business Address

Spouse’s Name

First Last

Occupation

Spouse’s Employer

Business Address

MEDICAL HISTORY

Is 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

Physician’s Name

Date of Last Evaluation

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

please list

Current state of health (explain):

Any history in your family of an eye turn resulting from a disease or other condition?

Yes

If yes, please explain

Was there any related trauma, disease, or condition that preceded or accompanied the onset of the eye turn?

Yes

If yes, please explain

Are you prone to infections?

Yes

Are there any chronic problems like ear infections, asthma, hay fever, allergies?

Yes

If yes, please list

List illnesses, bad falls, high fevers, ear infections, etc

Age

Severe

Mild

Complications

Has a neurological evaluation been performed?

Yes

By whom?

Results

Has a psychological evaluation been performed?

Yes

By whom?

Results

Has an occupational therapy evaluation been performed?

Yes

By whom?

Results

DEVELOPMENTAL HISTORY

Full-term pregnancy?

Yes

Did the mother experience any problems during the pregnancy?

Yes

If yes, explain

Normal birth?

Yes

If No, explain

Were forceps used?

Yes

Any complications before, during or immediately following delivery?

Yes

If yes, explain

Were there ever any concerns regarding growth or development?

Yes

If yes, explain

NUTRITIONAL INFORMATION

Current Diet

Excellent

Good

Fair

Poor

Do you (like /crave)

crave

- sweets?

Yes

Are there any indications that you have been exposed to any toxic substances or fumes?

Yes

If so, explain

VISUAL HISTORY

At 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)

out

down

Is the eye turn getting worse

worse

better

no change

Is it always the same eye that turns?

Yes

If yes, which eye?

Right

Left

Is the eye turn always present?

Yes

If not, under what conditions is it present?

Does the eye always turn the same amount?

Yes

If no, explain

Do you notice if the eye turns more when you look

Does one pupil ever appear to be larger than the other?

Yes

If yes, when?

Do you ever notice one or both eyes shaking rapidly?

Yes

If yes, when?

Do you experience any of the following

Yes

If yes, when?

Do you experience any of the following

Yes

If yes, when?

Headaches

Yes

If yes, when?

Blurred vision

Yes

If yes, when?

Double vision

Yes

If yes, when?

Eyes tired

Yes

If yes, when?

Eyes hurt

Yes

If yes, when?

Motion sickness / car sickness

Yes

If yes, when?

Frequent styes

Yes

If yes, when?

Red or bloodshot eyes

Yes

If yes, when?

Watery eyes

Yes

If yes, when?

Bothered by light

Yes

If yes, when?

Closing or covering an eye to see better

Yes

If yes, when?

Need to hold paper close when reading or writing

Yes

If yes, when?

Head tilt

Yes

If yes, when?

Confusion of letters or words

Yes

If yes, when?

Skipping or omitting words

Yes

If yes, when?

Loss of place when reading

Yes

If yes, when?

Need to use finger to keep place

Yes

If yes, when?

Poor reading comprehension

Yes

If yes, when?

Comprehension decreases over time

Yes

If yes, when?

Write or print poorly

Yes

If yes, when?

Fatigue easily

Yes

If yes, when?

Difficulty with short term memory

Yes

If yes, when?

Difficulty with long term memory

Yes

If yes, when?

Short attention span / loss of interest

Yes

If yes, when?

Difficulty attending to details

Yes

If yes, when?

Poor / awkward general motor coordination

Yes

If yes, when?

Poor fine motor coordination

Yes

If yes, when?

Difficulty judging distances

Yes

If yes, when?

Difficulty driving

Yes

If yes, when?

Dislike / avoid sports

Yes

If yes, when?

Difficulty hitting or judging moving targets during sports

Yes

If yes, when?

List any other complaints you have concerning vision

Do you feel your vision hinders your daily activities in any way?

Yes

If yes, explain

Do you feel your vision limits your potential in any way?

Yes

If yes, explain

PREVIOUS TREATMENTS

Have you had a previous visual evaluation

Yes

If yes, Doctor’s Name

Date of last evaluation

Results and recommendations

Were glasses, contact lenses, or other optical devices recommended or prescribed?

Yes

If yes,

bifocal?

single vision?

contact lenses?

Other

Are they worn?

Yes

If yes, when?

If no, why not?

Does the eye turn less when the prescription is worn?

Yes

Unsure

Have you been told that you have amblyopia (lazy eye)?

Yes

Has there been any treatment using an eye patch?

Yes

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 results

Has there been any surgical treatment?

Yes

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 results

Was the surgeon satisfied with the results of surgery?

Yes

Explain

Were you satisfied with the results of surgery?

Yes

Explain

Have surgical results been maintained?

Yes

Explain

Has there been any visual therapy?

Yes

If yes, Doctor’s name

Please describe the type of visual therapy, including duration, the age at which it started and an estimate of results

Are you here for a second opinion regarding surgery or other treatment?

Yes

EMPLOYMENT OR SCHOOL

Current 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

Do you feel you are getting adequate return for the amount of effort you put into a task?

Yes

Does your work or course of study demand comprehension from the written word?

Yes

Describe briefly your daily activities at work or in school

HOBBIES/LEISURE TIME

Describe the types of activities that comprise the majority of your spare time

Do you watch TV?

Yes

If yes, how many hours per day?

How many days per week?

Are you seriously involved with athletics?

Yes

Do you feel you are achieving up to your potential in athletics?

Yes

Of all the sports you have played:

List the ones in which you excel

List the ones in which you do poorly / avoid

Do you feel your vision limits or prevents you from participating in any activities?

Yes

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

If yes, explain

Release Of Information and Insurance Filing

Signature of patient or authorized representative(Required)

Date

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.

Adult Extended Questionnaire

GENERAL INFORMATION

MEDICAL HISTORY

DEVELOPMENTAL HISTORY

NUTRITIONAL INFORMATION

VISUAL HISTORY

PREVIOUS TREATMENTS

EMPLOYMENT OR SCHOOL

HOBBIES/LEISURE TIME

Of all the sports you have played:

Release Of Information and Insurance Filing

Vision Source Specialists