Vision Rehabilitation Questionnaire Form Vision Rehabilitation Questionnaire Please enable JavaScript in your browser to complete this form.1Information2Medical History3Initial Treatment4Visual History5Lifestyle6Information ReleasePatient InformationAppointment Date & Time *DateTimeName on Care Card (Last, First) *Date of Birth (MM/DD/YY) *PHN (Care card number) *Gender *Address *City *Postal Code *Home PhoneWork PhoneOccupationLast Eye ExamFamily DoctorEmployerWere you referred to our office? *YESNOIf yes, whom may we thank for this referral? *Referral’s Phone Number *Referral’s Address *Do you have extended health? *YESNOInsurance Company *Insured Member Name (Last, First) *Patient Relationship to Insured Member *Policy Number *Member ID *Do you have secondary coverage? *YESNOInsurance Company *Insured Member Name (Last, First) *Patient Relationship to Insured Member *Policy Number *Member ID *NextMedical HistoryDate of injury/accidentPlease indicate the type of injury/accident you experienced:Motor vehicleFallBlow to headIndustrial AccidentMedication-relatedDrug abusePoison or toxic substanceCarbon dioxideDrowningCord around neckStrokeAneurysmHemorrhageOther (explain)Please indicate the type of injury/accident you experienced (Other) *What part of your head was affected? (check all that apply):ForeheadRight sideLeft sideBack of headTop of headFaceWas the injury OPEN HEAD (bleeding) or CLOSED HEAD (non-bleeding)?Did you lose consciousness?YESNOIf yes, for how long? *Were you in a coma?YESNOIf yes, for how long? *Symptoms IMMEDIATELY following accident/injury (check all that apply):Double visionHeadacheBlurred visionPain in or around eyesDizzinessVomitingFlashes of lightDisorientationLoss of balanceNeck pain/whiplashLoss of memoryRestricted field of viewRestricted motionOther (explain)Symptoms IMMEDIATELY following accident/injury (Other) *Is there any history of the following? (please check if there is a history)High blood pressurePatientFamilyPlease Specify *DiabetesPatientFamilyPlease Specify *Thyroid conditionPatientFamilyPlease Specify *Multiple SclerosisPatientFamilyPlease Specify *Brain TumorPatientFamilyPlease Specify *StrokePatientFamilyPlease Specify *GlaucomaPatientFamilyPlease Specify *CataractsPatientFamilyPlease Specify *BlindnessPatientFamilyPlease Specify *StrabismusPatientFamilyPlease Specify *Amblyopia (lazy eye)PatientFamilyPlease Specify *Traumatic brain injuryPatientFamilyPlease Specify *PreviousNextInitial TreatmentWhen did you first see a doctor regarding your accident/injury?Name of DoctorSpecialtyWhere were you seen?Were you hospitalized? *YESNOIf yes, for 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? *YESNOIf yes, please list *For what condition(s)? *List any medications, including vitamins and supplements used at the current time:What types of professional care have you received or are you currently receiving? (check all that apply and describe)PhysicianPhysicianName *Date *Results and recommendations *NeurologistNeurologistName *Date *Results and recommendations *Neuro- psychologistNeuro-psychologistName *Date *Results and recommendations *Physical TherapistPhysical TherapistName *Date *Results and recommendations *Speech / Language TherapistSpeech / Language TherapistName *Date *Results and recommendations *Psychologist / PsychiatristPsychologist / PsychiatristName *DateResults and recommendations *ChiropractorChiropractorName *Date *Results and recommendations *Occupational TherapistOccupational TherapistName *Date *Results and recommendations *Registered Massage TherapistsRegistered Massage TherapistsName *Date *Results and recommendations *OtherOtherName *Date *Results and recommendations *Do you have a history of allergies?YESNOIf yes, please explain *Has a neurological evaluation been performed?YESNOIf yes, by whom *Date *Results *Has a psychological evaluation been performed?YESNOIf yes, by whom *Date *Results *Has a speech language evaluation been performed?YESNOIf yes, by whom *Date *Results *PreviousNextVisual HistoryHave you had a previous vision examination? *YESNOIf 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? *YESNOIf so, what have you been prescribed, and how long have you had them for? *Do you currently used them? *YESNOIf used, how often do you use them (i.e. hrs/day, times per week)? *If not, why not? *Were any additional tests, treatments, or therapies recommended concerning your vision?YESNOIf yes, what? *Did you undergo these treatments?YESNOIf yes, please explain *Results and recommendations *Please indicate if you are CURRENTLY experience any of the following:Eyes acheYesNoPrior to injury?Eyes pull or tugYesNoPrior to injury?Difficulty moving or turning eyesYesNoPrior to injury?Pain with movement of eyesYesNoPrior to injury?Eyes twitchYesNoPrior to injury?Pain in or around eyesYesNoPrior to injury?Eye rednessYesNoPrior to injury?Burning eyesYesNoPrior to injury?Watery eyesYesNoPrior to injury?Itchy eyesYesNoPrior to injury?Brightness is bothersomeYesNoPrior to injury?Motion sickness / car sicknessYesNoPrior to injury?HeadachesYesNoPrior to injury?Blurred visionYesNoPrior to injury?Difficulty changing focus far to nearYesNoPrior to injury?Double visionYesNoPrior to injury?One eye turns in, out, up or downYesNoPrior to injury?Movement of objects in the environment is bothersomeYesNoPrior to injury?Fluorescent light is bothersomeYesNoPrior to injury?Patterned wallpaper or carpets are bothersomeYesNoPrior to injury?Head moves when readingYesNoPrior to injury?Lose place often when readingYesNoPrior to injury?Words jump or move around when readingYesNoPrior to injury?Short attention span for reading or writingYesNoPrior to injury?Skip words frequently when readingYesNoPrior to injury?Discomfort when readingYesNoPrior to injury?Loss of interest/concentration when doing close workYesNoPrior to injury?Orient writing/drawing poorly on pageYesNoPrior to injury?Squinting, covering or closing one eyeYesNoPrior to injury?Head tilts during desk workYesNoPrior to injury?Hold books too closeYesNoPrior to injury?Avoid reading or writingYesNoPrior to injury?Difficulty with peripheral visionYesNoPrior to injury?Objects jump in and out of field of viewYesNoPrior to injury?Reduced depth perceptionYesNoPrior to injury?Tunnel vision / Loss of visual fieldYesNoPrior to injury?Flashes of lightYesNoPrior to injury?Difficulty with dressingYesNoPrior to injury?Difficulty with bathing / personal hygieneYesNoPrior to injury?Difficulty following a series of directionsYesNoPrior to injury?Difficulty using both sides of the body togetherYesNoPrior to injury?Dislike heightsYesNoPrior to injury?Awkward, poor balanceYesNoPrior to injury?DizzinessYesNoPrior to injury?Confusion / disorientationYesNoPrior to injury?Get lost oftenYesNoPrior to injury?Bothered by noisesYesNoPrior to injury?Bothered by touchYesNoPrior to injury?Difficulty remembering things heardYesNoPrior to injury?Difficulty remembering things seenYesNoPrior to injury?Difficulty remembering name of objectsYesNoPrior to injury?Difficulty remembering people’s namesYesNoPrior to injury?Difficulty recalling information known in the pastYesNoPrior to injury?Difficulty remembering formerly familiar people / objectsYesNoPrior to injury?Difficulty performing tasks formerly easy / routineYesNoPrior to injury?Difficulty with time managementYesNoPrior to injury?Difficulty with numbersYesNoPrior to injury?Difficulty counting moneyYesNoPrior to injury?Why do you feel the need for a vision evaluation today?PreviousNextLifestyle SituationDo you feel your vision interferes with activities of daily living?YESNOIf yes, please explain (please include effects involving home, work, hobbies, social and personal relationships): *What activities compromise 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 Vision Rehabilitation Program can do for you?EMPLOYMENT/EDUCATION INFORMATION (if applicable)What is your 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?PreviousNextRelease of InformationIt 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. PreviousSubmit