Appointment

Date

Time

Patient’s Name

First Last

GENERAL INFORMATION

Patient Name(Required)

First Last

Male

Female

Birth Date

Age

Address

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

Home Phone(Required)

Work Phone

Marital status

Single

Married

Divorced

Widowed

Were you referred to our office?

Yes

Were you referred to our office?

Yes

whom may we thank for this referral?

Phone

Address

Do you have Major Medical Insurance?

Yes

who is the carrier?

Policy #:

Does the insurance cover eye examinations or glasses?

Yes

Primary Insurance

Policy #

Secondary Insurance

Policy #

Social Security Number

Driver’s License No.

What is your occupation?

Employer

Business Address

Spouse’s Name

First Last

Occupation:

Spouse’s Employer:

Phone

Business Address:

MEDICAL HISTORY

Date of injury/accident:

Type of injury/accident:

WHAT PART OF YOUR HEAD WAS AFFECTED? (check all that apply):

Forehead

Right side

Left side

Back of head

Top of head

Face

Was the injury OPEN HEAD (bleeding) or CLOSED HEAD (non-bleeding)?

Did you lose consciousness?

Yes

for how long?

Were you in a coma?

Yes

how long?

SYMPTOMS IMMEDIATELY FOLLOWING ACCIDENT/INJURY: (check all that apply)

Other

INITIAL TREATMENT

When did you first see a doctor regarding your accident/injury?

Name of Doctor:

Specialty:

Where were you seen?

Were you hospitalized?

Yes

How long?

What were you and your family told?

What did the initial treatments consist of?

What prognosis/recommendations were you given?

Were you given medications?

Yes

Medication:

For what condition(s)?

List any medications, including vitamins and supplements used at the current time:

SUBSEQUENT/OTHER PROFESSIONALCARE

Physicians Name:

Date

Results and recommendations

Physiatrist Name:

Date

Results and recommendations

Neurologist Name:

Date

Results and recommendations

Physical Therapist Name:

Date

Results and recommendations

Speech / Language Therapist Name:

Date

Results and recommendations

Psychologist / Psychiatrist Name:

Date

Results and recommendations

Osteopathic Physicians Name:

Date

Results and recommendations

Other / Name:

Date

Results and recommendations

Do you have a history of allergies?

Yes

please explain

Has a neurological evaluation been performed?

Yes

by whom?

Date

Results:

Has a psychological evaluation been performed?

Yes

by whom?

Date

Results:

Has a speech and language evaluation been performed?

Yes

by whom?

Date

Results:

MEDICAL HISTORY

Is there any history of the following? (please check if there is a history)

Is there any Family history of the following?

High blood pressure (Who)

Diabetes (Who)

Thyroid condition (Who)

Multiple Sclerosis (Who)

Brain Tumor (Who)

Stroke (Who)

Glaucoma (Who)

Cataracts (Who)

Blindness (Who)

Strabismus (Who)

Amblyopia (Who)

Traumatic brain injury (Who)

VISUAL HISTORY

Have you had a previous vision evaluation?

Yes

doctor’s name:

Date of last evaluation

Reason for examination

Were glasses, contact lenses or other optical devices recommended

Yes

what?

Are they used?

Yes

when?

why not?

Were any additional tests, treatments, or therapies recommended concerning your vision?

Yes

what?

Did you undergo these treatments?

Yes

Explain

Results and recommendations

DO YOU CURRENTLY EXPERIENCE ANY OF THE FOLLOWING

Eyes ache

Yes

Prior to Injury?

Eyes pull or tug

Yes

Prior to Injury?

Difficulty moving or turning eyes

Yes

Prior to Injury?

Pain with movement of eyes

Yes

Prior to Injury?

Eyes twitch

Yes

Prior to Injury?

Pain in or around eyes

Yes

Prior to Injury?

Eye redness

Yes

Prior to Injury?

Burning eyes

Yes

Prior to Injury?

Watery eyes

Yes

Prior to Injury?

Itchy eyes

Yes

Prior to Injury?

Brightness is bothersome

Yes

Prior to Injury?

Motion sickness / car sickness

Yes

Prior to Injury?

Headaches

Yes

Prior to Injury?

Blurred vision

Yes

Prior to Injury?

Difficulty changing focus far to near

Yes

Prior to Injury?

Double vision

Yes

Prior to Injury?

One eye turns in, out, up or down

Yes

Prior to Injury?

Movement of objects in the environment is bothersome

Yes

Prior to Injury?

Fluorescent light is bothersome

Yes

Prior to Injury?

Patterned wallpaper or carpets are bothersome

Yes

Prior to Injury?

Head moves when reading

Yes

Prior to Injury?

Lose place often when reading

Yes

Prior to Injury?

Words jump or move around when reading

Yes

Prior to Injury?

Short attention span for reading or writing

Yes

Prior to Injury?

Skip words frequently when reading

Yes

Prior to Injury?

Discomfort when reading

Yes

Prior to Injury?

Loss of interest/concentration when doing close work

Yes

Prior to Injury?

Orient writing/drawing poorly on page

Yes

Prior to Injury?

Squinting, covering or closing one eye

Yes

Prior to Injury?

Head tilts during desk work

Yes

Prior to Injury?

Hold books too close

Yes

Prior to Injury?

Avoid reading or writing

Yes

Prior to Injury?

Difficulty with peripheral vision

Yes

Prior to Injury?

Objects jump in and out of field of view

Yes

Prior to Injury?

Reduced depth perception

Yes

Prior to Injury?

Tunnel vision / Loss of visual field

Yes

Prior to Injury?

Flashes of light

Yes

Prior to Injury?

Difficulty with dressing

Yes

Prior to Injury?

Difficulty with bathing / personal hygiene

Yes

Prior to Injury?

Difficulty following a series of directions

Yes

Prior to Injury?

Difficulty using both sides of the body together

Yes

Prior to Injury?

Dislike heights

Yes

Prior to Injury?

Awkward, poor balance

Yes

Prior to Injury?

Dizziness

Yes

Prior to Injury?

Confusion / disorientation

Yes

Prior to Injury?

Get lost often

Yes

Prior to Injury?

Bothered by noises

Yes

Prior to Injury?

Bothered by touch

Yes

Prior to Injury?

Difficulty remembering things heard

Yes

Prior to Injury?

Difficulty remembering things seen

Yes

Prior to Injury?

Difficulty remembering name of objects

Yes

Prior to Injury?

Difficulty remembering people’s names

Yes

Prior to Injury?

Difficulty recalling information known in the past

Yes

Prior to Injury?

Difficulty remembering formerly familiar people / objects

Yes

Prior to Injury?

Difficulty performing tasks formerly easy / routine

Yes

Prior to Injury?

Difficulty with time management

Yes

Prior to Injury?

Difficulty with numbers

Yes

Prior to Injury?

Difficulty counting money

Yes

Prior to Injury?

Why do you feel the need for a vision evaluation today?

LIFESTYLE

Do you feel your vision interferes with activities of daily living?

Yes

If yes, please explain (please include effects involving home, work, hobbies social and personal relationships)

What activities comprise the majority of your daily life since your accident/injury?

What activities can you no longer engage in due to your visual or other difficulties?

What other changes/limitations in your daily life do you attribute to your accident/injury?

What do you hope a Visual Rehabilitation Program can do for you?

EMPLOYMENT/EDUCATION INFORMATION (IF APPLICABLE)

What is current employment position?

If a student, what is the major course of study?

How many hours daily are spent at a desk?

How many hours daily are spent working at near distance?

How many hours daily are spent reading/studying?

How many hours daily are spent with a computer?

Release Of Information and Insurance Filing

It 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.

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, OD

Rehab Questionnaire – PVTC

GENERAL INFORMATION

MEDICAL HISTORY

INITIAL TREATMENT

SUBSEQUENT/OTHER PROFESSIONALCARE

MEDICAL HISTORY

VISUAL HISTORY

DO YOU CURRENTLY EXPERIENCE ANY OF THE FOLLOWING

LIFESTYLE

EMPLOYMENT/EDUCATION INFORMATION (IF APPLICABLE)

Release Of Information and Insurance Filing

Vision Source Specialists