ADULT VISION QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of the medical record.

Full Name

First Last

DOB

Address

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

Home Phone

Work Phone

Cell Phone

Marital status:

How did you hear about us?(Required)

Occupation:

Employer:

Address:

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

Spouse:

Spouse’s Phone Number:

MEDICAL HISTORY

What is the primary reason you are seeking a vision evaluation?

List last medical evaluation(physician’s name, date, problem and recommendation)

Medications currently using, including vitamins and supplements:

Yes

Medication

For what condition

Allergies to food and medications:

Yes

List allergies:

Are you prone to infections?

Yes

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

Yes

List Illnesses, Bad Falls, High Fevers, etc.

Age

Illness

Severity(mild, severe)

Complications

Has a neurological evaluation been performed?

Yes

By whom?

Results and recommendations:

Has a psychological evaluation been performed?

Yes

By whom?

Results and recommendations:

Has an occupational therapy evaluation been performed?

Yes

By whom?

Results and recommendations:

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

Diabetes

Patient

Family

who

Blindness

Patient

Family

Who

Eye Turn

Patient

Family

Who

Glaucoma

Patient

Family

Who

Multiple Sclerosis

Patient

Family

Who

Brain Tumor

Patient

Family

Who

Cancer

Patient

Family

Who

High Blood Pressure

Patient

Family

Who

Eye Infection

Patient

Family

Who

Thyroid Condition

Patient

Family

Who

Eye Surgery

Patient

Family

Who

Cataracts

Patient

Family

Who

Lazy eye

Patient

Family

Who

Eye Disease

Patient

Family

Who

VISUAL HISTORY

Have you had a previous eye examination?

Yes

Doctor’s name:

First Last

Date of last evaluation:

Reason for evaluation:

Results and recommendations:

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

Yes

what?

Do you use them?

Yes

When?

Why not?

How long have you had them?

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

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

What solutions do you use?

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

Name?

Age?

Visual Situation?

PRESENT SITUATION

Do you experience any of the following symptoms?

Headaches

Yes

When?

Blurred vision

Yes

When?

Double vision

Yes

When?

Eyes tired

Yes

When?

Eyes hurt

Yes

When?

Motion sickness/car sickness

Yes

when?

Frequent sties

Yes

When?

Red or bloodshot eyes

Yes

When?

Watery eyes

Yes

When?

Bothered by light/light sensitivity

Yes

When?

Closing or covering an eye to see better

Yes

When?

Need to hold paper close when reading or writing

Yes

When?

Head tilt

Yes

When?

Confusion of letters or words

Yes

when?

Skipping or omitting words

Yes

When?

Loss of place when reading

Yes

when?

Need to use finger to keep place

Yes

When?

Head moves when reading

Yes

when?

Silent vocalization/moving lips while reading

Yes

When?

Confusion of what is being seen or read

Yes

When?

Letters or words appear to move or float around when reading

Yes

When?

Difficulty aligning columns of numbers

Yes

When?

Poor reading comprehension

Yes

When?

Comprehension decrease over time

Yes

When?

Falling asleep when reading

Yes

When?

Writes or prints poorly

Yes

When?

Can respond better orally than in writing

Yes

When?

Tires easily

Yes

When?

Difficulty with short term memory

Yes

When?

Difficulty with long term memory

Yes

When?

Short attention span or loss of interest

Yes

When?

Difficulty attending to detail

Yes

When?

Poor/awkward general motor coordination

Yes

When?

Poor fine motor coordination

Yes

When?

Difficulty judging distances

Yes

When?

Difficulty driving

Yes

When?

Dislike/avoid sports

Yes

When?

Nausea associated with visual tasks

Yes

When?

Halos around light

Yes

When?

Tilt head during desk work

Yes

When?

Squinting, covering or closing one eye

Yes

When?

Postural changes when doing desk work

Yes

When?

Need for very bright light or dim light when reading

Yes

When?

Loss of interest or short attention span for close work

Yes

When?

Difficulty sustaining reading or writing

Yes

When?

General or visual fatigue at the end of the day

Yes

When?

Poor time management

Yes

When?

Inconsistent performance in work or sports

Yes

When?

Difficulty hitting or judging moving targets during sports

Yes

When?

List any other complaints you have concerning vision:

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

Yes

explain:

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

Yes

explain:

COMPUTERS

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

Yes

WORD PROCESSING

PROGRAMMING

DATA ENTRY

INTERNET

GAMES/LEISURE

OTHER

EXPLAIN

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 eye level

At eye level

Below eye level

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

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 do you spend working at near distances?

Are you achieving your potential at work or school?

Yes

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

Yes

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

Yes

Describe briefly your daily activities at work or in school:

HOBBIES AND LEISURE TIME

Describe the types of activities you do in your spare time:

Are you seriously involved with athletics?

Yes

Do you feel you are achieving your potential in athletics?

Yes

Which sports do you excel in?

Which sports do you do poorly in?

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

Yes

Explain:

Is there any information you feel would be helpful in our evaluation and treatment?

Yes

Explain:

IF YOU HAVE A HISTORY OF EYE TURN/LAZY EYE/WANDERING EYE, PLEASE COMPLETE THE FOLLOWING SECTION, IF NOT PLEASE SKIP TO THE NEXT SECTION.

AMBLYOPIA/STRABISMUS HISTORY

What age was the eye turn first noticed or suspected?

Did it begin turning

Suddenly

Gradually?

Does the eye turn

out

Down

(Check all that apply)

Is the eye turn getting

Worse

Better

No Change?

Is it always the same eye that turns?

Yes

which eye?

Right

Left

Is the eye turn always present?

Yes

under what conditions is it present:

Does the eye always turn in the same amount?

Yes

explain:

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

Yes

explain?

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

Yes

explain:

Do you notice the eye turns more when you look:

Up close?

Yes

In the distance?

Yes

To the left?

Yes

To the right?

Yes

Up?

Yes

Down?

Yes

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

Yes

Do you ever notice one or both eyes shaking rapidly?

Yes

If you have a prescription, does the eye turn less when the prescription is worn?

Yes

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

Yes

Has there been any treatment using an eye patch?

Yes

please describe when the patching was started, how much patching was done?

(include age started, duration, eye patched and results)

Has there been any surgical treatment?

Yes

please describe the surgery?

(include age when surgery was performed, # of operations, the eye operated on and results)

Was the surgeon satisfied with the results of surgery?

Yes

Explain:

Were you satisfied with the results of surgery?

Yes

Explain:

Have the surgical results been maintained?

Yes

Explain:

Has there been any visual therapy?

Yes

Doctors Name:

First Last

Please describe the type of visual therapy, including duration, age at which it was started and estimated results:

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

Yes

IF YOU HAVE A HISTORY OF HEAD INJURY, PLEASE COMPLETE THE FOLLOWING SECTION.

BRAIN INJURY HISTORY

Date of injury/accident:

Type of injury/accident:

What part of their head was affected:

Forehead

Right side

Left side

Back of head

Top of head

Face

N/A

Was the injury:

Open Head (bleeding)

Closed Head (non-bleeding)

Did they lose consciousness?

Yes

for how long:

Were they in a coma?

Yes

for how long:

Symptoms immediately following the accident/injury:

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

Name of Doctor:

First Last

Specialty:

Where were they seen?

Were you hospitalized?

Yes

What were you and your family told?

What did the initial treatments consist of?

What prognosis/recommendations were they given?

Were you given medications?

Yes

Please list

Name medication

For what condition

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?

LIFESTYLE

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

Yes

please explain (please include effects involving home, work, hobbies and personal relationships):

SUBSEQUENT/OTHER PROFESSIONAL CARE

What types of professional care have you received or are you currently receiving? (check all that apply)

Physician

Yes

Name

First Last

Date

Results:

Physiatrist

Yes

Name

First Last

Date

Results:

Neurologist

Yes

Name

First Last

Date

Results:

Neurophysiologist

Yes

Name

First Last

Date

Results:

Physical Therapist

Yes

Name

First Last

Date

Results:

Speech/Language Therapist

Yes

Name

First Last

Date

Results:

Psychologist/Psychiatrist

Yes

Name

First Last

Date

Results:

Osteopathic Physician

Yes

Name

First Last

Date

Results:

Other

Yes

Name

First Last

Date

Results:

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Date(Required)

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ADULT VISION QUESTIONNAIRE

MEDICAL HISTORY

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

VISUAL HISTORY

PRESENT SITUATION

COMPUTERS

EMPLOYMENT OR SCHOOL

HOBBIES AND LEISURE TIME

AMBLYOPIA/STRABISMUS HISTORY

BRAIN INJURY HISTORY

LIFESTYLE

SUBSEQUENT/OTHER PROFESSIONAL CARE

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