Vision Rehabilitation Questionnaire Form

Vision Rehabilitation Questionnaire

1Information

2Medical History

3Initial Treatment

4Visual History

5Lifestyle

6Information Release

Patient Information

Appointment Date & Time *

Date

Time

Name on Care Card (Last, First) *

Date of Birth (MM/DD/YY) *

PHN (Care card number) *

Gender *

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 injury/accident

Please indicate the type of injury/accident you experienced:

Motor vehicle
Fall
Blow to head
Industrial Accident
Medication-related
Drug abuse
Poison or toxic substance
Carbon dioxide
Drowning
Cord around neck
Stroke
Aneurysm
Hemorrhage
Other (explain)

Please indicate the type of injury/accident you experienced (Other) *

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?

If yes, for how long? *

Were you in a coma?

If yes, for how long? *

Symptoms IMMEDIATELY following accident/injury (check all that apply):

Double vision
Headache
Blurred vision
Pain in or around eyes
Dizziness
Vomiting
Flashes of light
Disorientation
Loss of balance
Neck pain/whiplash
Loss of memory
Restricted field of view
Restricted motion
Other (explain)

Symptoms IMMEDIATELY following accident/injury (Other) *

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

High blood pressure

Patient
Family

Please Specify *

Diabetes

Patient
Family

Please Specify *

Thyroid condition

Patient
Family

Please Specify *

Multiple Sclerosis

Patient
Family

Please Specify *

Brain Tumor

Patient
Family

Please Specify *

Stroke

Patient
Family

Please Specify *

Glaucoma

Patient
Family

Please Specify *

Cataracts

Patient
Family

Please Specify *

Blindness

Patient
Family

Please Specify *

Strabismus

Patient
Family

Please Specify *

Amblyopia (lazy eye)

Patient
Family

Please Specify *

Traumatic brain injury

Patient
Family

Please Specify *

Initial Treatment

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

Name of Doctor

Specialty

Where were you seen?

Were you hospitalized? *

If 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? *

If 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)

Physician

Physician

Name *

Date *

Results and recommendations *

Neurologist

Neurologist

Name *

Date *

Results and recommendations *

Neuro- psychologist

Neuro-psychologist

Name *

Date *

Results and recommendations *

Physical Therapist

Physical Therapist

Name *

Date *

Results and recommendations *

Speech / Language Therapist

Speech / Language Therapist

Name *

Date *

Results and recommendations *

Psychologist / Psychiatrist

Psychologist / Psychiatrist

Name *

Date

Results and recommendations *

Chiropractor

Chiropractor

Name *

Date *

Results and recommendations *

Occupational Therapist

Occupational Therapist

Name *

Date *

Results and recommendations *

Registered Massage Therapists

Registered Massage Therapists

Name *

Date *

Results and recommendations *

Other

Other

Name *

Date *

Results and recommendations *

Do you have a history of allergies?

If yes, please explain *

Has a neurological evaluation been performed?

If yes, by whom *

Date *

Results *

Has a psychological evaluation been performed?

If yes, by whom *

Date *

Results *

Has a speech language evaluation been performed?

If yes, by whom *

Date *

Results *

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? *

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

If yes, what? *

Did you undergo these treatments?

If yes, please explain *

Results and recommendations *

Please indicate if you are CURRENTLY experience any of the following:

Eyes ache

Yes
No
Prior to injury?

Eyes pull or tug

Yes
No
Prior to injury?

Difficulty moving or turning eyes

Yes
No
Prior to injury?

Pain with movement of eyes

Yes
No
Prior to injury?

Eyes twitch

Yes
No
Prior to injury?

Pain in or around eyes

Yes
No
Prior to injury?

Eye redness

Yes
No
Prior to injury?

Burning eyes

Yes
No
Prior to injury?

Watery eyes

Yes
No
Prior to injury?

Itchy eyes

Yes
No
Prior to injury?

Brightness is bothersome

Yes
No
Prior to injury?

Motion sickness / car sickness

Yes
No
Prior to injury?

Headaches

Yes
No
Prior to injury?

Blurred vision

Yes
No
Prior to injury?

Difficulty changing focus far to near

Yes
No
Prior to injury?

Double vision

Yes
No
Prior to injury?

One eye turns in, out, up or down

Yes
No
Prior to injury?

Movement of objects in the environment is bothersome

Yes
No
Prior to injury?

Fluorescent light is bothersome

Yes
No
Prior to injury?

Patterned wallpaper or carpets are bothersome

Yes
No
Prior to injury?

Head moves when reading

Yes
No
Prior to injury?

Lose place often when reading

Yes
No
Prior to injury?

Words jump or move around when reading

Yes
No
Prior to injury?

Short attention span for reading or writing

Yes
No
Prior to injury?

Skip words frequently when reading

Yes
No
Prior to injury?

Discomfort when reading

Yes
No
Prior to injury?

Loss of interest/concentration when doing close work

Yes
No
Prior to injury?

Orient writing/drawing poorly on page

Yes
No
Prior to injury?

Squinting, covering or closing one eye

Yes
No
Prior to injury?

Head tilts during desk work

Yes
No
Prior to injury?

Hold books too close

Yes
No
Prior to injury?

Avoid reading or writing

Yes
No
Prior to injury?

Difficulty with peripheral vision

Yes
No
Prior to injury?

Objects jump in and out of field of view

Yes
No
Prior to injury?

Reduced depth perception

Yes
No
Prior to injury?

Tunnel vision / Loss of visual field

Yes
No
Prior to injury?

Flashes of light

Yes
No
Prior to injury?

Difficulty with dressing

Yes
No
Prior to injury?

Difficulty with bathing / personal hygiene

Yes
No
Prior to injury?

Difficulty following a series of directions

Yes
No
Prior to injury?

Difficulty using both sides of the body together

Yes
No
Prior to injury?

Dislike heights

Yes
No
Prior to injury?

Awkward, poor balance

Yes
No
Prior to injury?

Dizziness

Yes
No
Prior to injury?

Confusion / disorientation

Yes
No
Prior to injury?

Get lost often

Yes
No
Prior to injury?

Bothered by noises

Yes
No
Prior to injury?

Bothered by touch

Yes
No
Prior to injury?

Difficulty remembering things heard

Yes
No
Prior to injury?

Difficulty remembering things seen

Yes
No
Prior to injury?

Difficulty remembering name of objects

Yes
No
Prior to injury?

Difficulty remembering people’s names

Yes
No
Prior to injury?

Difficulty recalling information known in the past

Yes
No
Prior to injury?

Difficulty remembering formerly familiar people / objects

Yes
No
Prior to injury?

Difficulty performing tasks formerly easy / routine

Yes
No
Prior to injury?

Difficulty with time management

Yes
No
Prior to injury?

Difficulty with numbers

Yes
No
Prior to injury?

Difficulty counting money

Yes
No
Prior to injury?

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

Lifestyle Situation

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

If 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?

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.