Patient Name:   Today's Date:11/28/2014
DOB: / /            Your age:   Sex:    
Name of your Personal / Family Doctor:  
1. Of all your symptoms, which two are the ones that cause you the most problems?
Worst Symptom: 
If other please state: How long have you had it?   /            
Second worst symptom: 
If other please state: How long have you had it?   /          
2. Whats kinds of Doctors/Specialists/Other Providers have you seen for these symptoms? (Check all that apply):




If other please state:
3. Doctors/Specialists/Other Providers you are currently seeing:
Name: Specialty:
Name: Specialty:
Name: Specialty:
4. Tests you've had performed (Check all that apply):


  If other please state:
5. Please list medications you are taking for headaches, pain, dizziness, anxiety or psychiatric reasons, TBI or ADD / ADHD. (Also, any medications that you are taking as a sleeping aid or muscle relaxer.) Use the drop-down lists to select medication and reason for taking it.

Drug Name

Reason For Taking Medicine:

1 .  
2. 
3. 
4. 
5. 
6. 
6. Please list medications you are taking for everything else, including Over-the-Counter (OTC) or Alternative / Dietary Supplements. Type name of medication and reason for taking it in the appropriate boxes below.

Drug Name

Reason For Taking Medicine:
1. 
2. 
3. 
4. 
5. 
6. 
Medical History (Check No or Yes)       N     Y        N     Y      N     Y  
       N     Y          N     Y      

Cervical Spine Fusion

 
      

Cervical Spine Injury
 
     

Severe Headaches  
       N     Y  


Allergies  

Kidney Disease  

Skin Disorders  

Cataracts  

Sinus Disorders  

BPPV   


Arthritis  

High Blood Pres.  

Asthma  

Glaucoma  

Meniere's  

Sleep Apnea  


Diabetes  

Heart Disease  
HIV      
TMJ Problem  

Vertigo
 

Anxiety  


Cancer  
   
Thyroid Disorder  

Head Injury/TBI  

Dizziness  

ADD/ADHD  
       
Lazy Eye  

Migraines  

Tinnitus  

Agoraphobia
 

Eye Disease--If Yes, please list:  
 
 

Other Health Problems / Illness --If Yes, please list:
 
Do you use drugs? 

Do you use alcohol?
  

Do you use cigarettes / tobacco? 

Are you pregnant?
 
If Yes, how many months? 

Allergic to any medicines?
 
If Yes, Please list:
Family Medical History- Do any of your family members have these medical conditions? (Check No or Yes)
       N     Y   Relationship        N     Y   Relationship        N     Y   Relationship
Blindness   Macular Degeneration  
Heart Disease
 
Cataracts  
Retinal Detachment
 

Severe Headaches
 

Glaucoma
  

Diabetes
 

Dizziness
 
Other eye conditions If Yes, Relationship: If Yes, What Kind?
Personal Eye Information

Have you ever had an eye operation? 
Type: Date:   /   

Have you ever had an eye injury? 
Kind: Date:   / 

Do you wear glasses? 
Age at first pair: When are they worn:

Do you wear contacts? 
Age at first pair: When are they worn:
If you wear contacts, are your contacts comfortable?
Do you experience the following? (Check No or Yes)
       N     Y          N     Y         N     Y          N     Y  
Itchiness 
Sudden loss of vision
  
Nausea  
Drifting to one side while walking
 

Spots/Floaters
 

Flashes of light
 

Dizziness
 

Unsteadiness w/ walking
 
Dryness  
Tearing
 

Lightheadedness
 

Ear fullness- Right or Left
 

Gritty feeling in eyes
  

Redness
 

Motion Sickness
 

Poor depth perception
 

Watery eyes
 

General fatigue
 

Blurry near vision
 

Feeling uncoordinated
 

Burning eyes
 

Frequent urination  

Trouble working up close
 

Upper back or shoulder tension
 

Eye strain
 

Shortness of breath
 

Blurry distance vision
 

Neck ache
 

Sore eyes
 

Skin Rashes
 

Trouble seeing at night
 

Head tilt
 
      N     Y          N     Y           N     Y         N      Y   

Fatigue w/ reading
 

Heart Palpitations
 

Double vision
 

Facial pain
 

Trouble reading
 

Fainting
 

Shadowed/overlapping vision
 

Sinus pain/pressure
 

Difficulty w/ reading comprehension
 
   
Sensitivity to light
 

Headaches
 

Losing your place while reading
 
   
Problems w/ reflection or glare
 

Eye pain
 

Words run together w/ reading
 
   
Lightheadedness w/ close-up activities
 

Pain w/ movement of eyes
 

Skipping lines while reading
 
   
Lightheadedness w/ distance activities
 
   

Closing or covering one eye while reading
 
   
Feeling overwhelmed or anxious in crowds
 
   

Trouble learning at work, school or other activity
 
   
Anxiety associated w/ dizziness
 
   
     N      Y               

Trouble concentrating
 
           
Trouble being fit with, or adjusting to, a prior pair of glasses  
Feeling overwhelmed or anxious in large contained spaces with ceilings (malls, churches, airports, big box stores)  
Visual Demands

Occupation (or grade in school) 


Employer (or school)
 

Computer Use ...................
 
  Approx. distance to screen Are glasses worn?

Desk Work .......................
 
  Approx. distance to desk work Are glasses worn?

Classroom Work ...............
 
    Are glasses worn?
Far distance viewing (10 feet & beyond, include driving to work)       Are glasses worn?
What sports, hobbies or leisure activities do you participate in?

                                                                                                                                                                                             


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