Adult Vision Questionnaire Form

Adult Vision Questionnaire

1Information

2Medical History

3Visual History

4Present Situation

5Lifestyle

6Information Release

Patient Information

Appointment Date & Time *

Date

Time

Name on Care Card (Last, First) *

Date of Birth *

Gender *

PHN (Care Card Number) *

Address *

City *

Postal Code *

Home Phone

Work Phone

Occupation

Last Eye Exam

Family Doctor

Employer

Were you referred to our office? *

If yes, whom may we thank for this referral? *

Referral’s Phone Number *

Referral’s Address *

Do you have extended health? *

Insurance Company *

Insured Member Name (Last, First) *

Patient Relationship to Insured Member *

Policy Number *

Member ID *

Do you have secondary coverage? *

Insurance Company *

Insured Member Name (Last, First) *

Patient Relationship to Insured Member *

Policy Number *

Member ID *

Medical History

Date of most recent evaluation

Physician’s Name

For what problem/condition?

Results and recommendations

Medications currently using, including vitamins and supplements

For what conditions?

Are you allergic to any foods or medications?

If yes, please list *

Current Diet

Excellent
Good
Fair
Poor

Please explain your current state of health

Please indicate if you have had a history of any of the following conditions:

Diabetes

Patient
Family

Please Specify *

Multiple Sclerosis

Patient
Family

Please Specify *

Blindness

Patient
Family

Please Specify *

Glaucoma

Patient
Family

Please Specify *

High Blood Pressure

Patient
Family

Please Specify *

Strabismus (Crossed eyed)

Patient
Family

Please Specify *

Amblyopia (Lazy eye)

Patient
Family

Please Specify *

Thyroid Condition

Patient
Family

Please Specify *

Cataracts

Patient
Family

Please Specify *

Brain Tumor

Patient
Family

Please Specify *

Visual History

Have you had a previous vision examination? *

If yes, what is your doctor’s name? *

Date of last visit *

Reason for examination *

Results and recommendations *

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

If so, what have you been prescribed, and how long have you had them for? *

Do you currently used them? *

If used, how often do you use them (i.e. hrs/day, times per week)? *

If not, why not? *

If you wear contact lenses, how long have you worn them for?

What type of lenses do you have (i.e. hard, soft, gas-permeable)?

What solutions do you use (i.e. saline solution, hydrogen peroxide)?

Members of the family who have required visual attention and reason:

1. Family Member, Age, Visual Situation

2. Family Member, Age, Visual Situation

3. Family Member, Age, Visual Situation

Present Situation

Why do you feel the need for a visual evaluation?

How long has this problem/difficulty existed?

Please indicate if you have had a history of any of the following conditions:

Blurred vision at distance

If yes, when & how often? *

Blurred vision at near

If yes, when & how often? *

Red or itchy eyes

If yes, when & how often? *

Burning eyes

If yes, when & how often? *

Frequent sties

If yes, when & how often? *

Watery eyes

If yes, when & how often? *

Eyes hurt

If yes, when & how often? *

Eyes feel tired

If yes, when & how often? *

Headaches

If yes, when & how often? *

Nausea associated with visual tasks

If yes, when & how often? *

Halos around lights

If yes, when & how often? *

Double vision at distance

If yes, when & how often? *

Double vision at near

If yes, when & how often? *

Tilt head during desk work

If yes, when & how often? *

Squinting, covering or closing one eye

If yes, when & how often? *

Postural changes when doing desk work

If yes, when & how often? *

Need for very bright light when reading

If yes, when & how often? *

Need for very dim light when reading

If yes, when & how often? *

Loss of interest or short attention span for close work

If yes, when & how often? *

Difficulty sustaining reading / writing

If yes, when & how often? *

General or visual fatigue at the end of the day

If yes, when & how often? *

Loss of place often when reading

If yes, when & how often? *

Skip lines when reading

If yes, when & how often? *

Repetition of letter or words when reading

If yes, when & how often? *

Omission of words when reading / copying

If yes, when & how often? *

Use of finger to keep place

If yes, when & how often? *

Head moves when reading

If yes, when & how often? *

Confusion of what is being seen or read

If yes, when & how often? *

Falling asleep when reading

If yes, when & how often? *

Silent vocalization/moving lips when reading

If yes, when & how often? *

Motion / car sickness

If yes, when & how often? *

Difficulty with reading comprehension

If yes, when & how often? *

Comprehension decreases over time

If yes, when & how often? *

Letters or words appear to move or float around when reading

If yes, when & how often? *

Difficulty aligning columns of numbers

If yes, when & how often? *

Can respond better orally than in writing

If yes, when & how often? *

Write or print poorly

If yes, when & how often? *

Poor time management

If yes, when & how often? *

Inconsistent performance in work or sports

If yes, when & how often? *

Poor general coordination / clumsiness

If yes, when & how often? *

Poor fine motor coordination

If yes, when & how often? *

Difficulties with short-term memory

If yes, when & how often? *

Difficulties with long-term memory

If yes, when & how often? *

Comments on any items above:

Lifestyle

Do you use a computer in your work, school, or leisure time activities?

If so, indicate the types of computer work you perform: *

Word processing
Programming
Data entry
Internet
Internet
Other (explain)

Computer Work - Other *

How many hours do you spend in front of a computer screen each day? *

How do your eyes feel after working at the computer? *

Where is the top of the screen located? *

Above your straight-ahead eye level
At eye level
Below eye level

Your eyes to the screen? *

Your eyes to the keyboard? *

Your eyes to your source documents? *

Where is the computer screen located? *

Directly in front of you when seated
To your right
To your left

Where are your source documents located? *

Directly in front of you when seated
To your right
To your left
Flat (horizontal) or vertical

Do you experience any of the following lighting problems in your work area? *

Glare from windows or other light sources
Reflections on your computer screen
Difficulty reading source documents

Do you wear glasses, contact lenses, or other optical devices for computer work? *

Glasses
Contact lenses
Other (explain)

Do you wear glasses, contact lenses, or other optical devices for computer work? (Other) *

Please describe any problems you have with your vision, current glasses or contact lenses for computer work: *

What is your current position (job)?

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?

Do you feel you are achieving your maximum potential in work or school?

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

If no, please explain: *

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

Describe briefly your daily activities at work or in school:

Describe the types of activities that comprise the majority of your leisure time:

Do you watch TV?

If yes, how many hours per day? *

How many days per week? *

Are you seriously involved with athletics?

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

Of all the sports you have played:

List the ones in which you excel:

List the ones in which you do poorly/avoid:

Release of Information

It is often beneficial to us to discuss examination results and to exchange information with other professionals involved in your care. Please sign below to authorize the release of information.

I agree to permit information from, or copies of, my examination records to be exchanged with other health care providers upon their written request or upon the recommendation of EYELAB – DOCTORS OF OPTOMETRY when it is necessary for the treatment of my visual condition. This authorization shall be considered valid for the duration of treatment.

Type Full Name *

Date *

Cancellation Policy

Cancellation of appointment requires a minimum of 24 hour notice. A $50 cancellation or no-show fee will be required if appointment is cancelled within the 24 hour window.