Patient History

Patient Name :

Male Female

Date

Age :

E-mail :

Home Address :

City :

Zip :

Home Ph :

Work Ph :

Cell Ph :

Marital Status : Single Married Divorced Widowed Other

How were you referred to our office?

Phone :

Address :

City :

Zip :

Do you have Major Medical or Vision Insurance? Yes No

If yes, who is the carrier?

Policy # :

Primary Insurance :

Policy # :

Secondary Insurance :

Policy # :

Social Security Number :

Driver’s License No. :

What is your occupation?

Employer :

Business Address :

City :

Zip :

Spouse’s Name :

Occupation :

Spouse’s Employer :

Phone # :

Date of injury/accident :

Type of injury/accident :
Motor Vehicle
Hemorrhage
Stroke
Fall
Medication-Related
Carbon Dioxide
Cord Around Neck
Aneurysm
Blow to head
Drowning
Industrial Accident/ Poison or Toxic Substance
Tumor
Other

What part of you head was affected? (check all that apply) :
Forehead
Right side
Left head
Back head
Top of head
Face

Was your injury OPEN HEAD (bleeding) or CLOSED HEAD (non-bleeding)?

Did you lose consciousness? Yes No

If yes, for how long?

SYMPTOMS IMMEDIATELY FOLLOWING ACCIDENT/INJURY: (check all that apply)
Double Vision
Headache
Blurred Vision
Pain in or around eyes
Loss of balance
Dizziness
Vomiting
Flashes of light
Loss of memory
Neck pain/whiplash
Restricted Field of View
Restricted Motion
Disorientation
Other

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

Name of Doctor :

Specialty :

Where were you seen?

Were you hospitalized? Yes No

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? Yes No

Medication :

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?

Physicians Name :

Date :

Address :

City :

Zip :

Physiatrist Name :

Date :

Address :

City :

Zip :

Neurologist Name :

Date :

Address :

City :

Zip :

Physical Therapist Name :

Date :

Address :

City :

Zip :

Speech / Language Therapist Name :

Date :

Address :

City :

Zip :

Psychologist / Psychiatrist Name :

Date :

Address :

City :

Zip :

Osteopathic Physicians Name :

Date :

Address :

City :

Zip :

Occupational Therapist Name :

Date :

Address :

City :

Zip :

Do you have a history of allergies? Yes No

If yes, please explain :

Has a neurological evaluation been performed? Yes No

If yes, by whom?

Date :

Results :

Has a psychological evaluation been performed? Yes No

If yes, by whom?

Date :

Results :

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

High blood pressure Patient Family

Glaucoma Patient Family

Diabetes Patient Family

Cataracts Patient Family

Thyroid condition Patient Family

Blindness Patient Family

Multiple Sclerosis Patient Family

Strabismus Patient Family

Brain Tumor Patient Family

Amblyopia Patient Family

Stroke Patient Family

Traumatic brain injury Patient Family

Have you had a previous vision evaluation : Yes No

If yes, doctor’s name :

Date :

Address :

Reason for examination :

Were glasses, contact lenses or other optical devices recommended? Yes No

If yes, what?

Are they used? Yes No

If yes, when?

If no, why not?

Were any additional tests, treatments, or therapies recommended concerning your vision? Yes No

Did you undergo these treatments? Yes No

Explain :

Results and Recommendations :

Eyes ache 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 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?

Difficulty writing/drawing on page Yes No Prior to Injury?

Squinting, covering or closing one eye Yes No Prior to Injury?

Head tilts during deskwork Yes No Prior to Injury?

Hold books too close when 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 following a series of directions Yes No Prior to Injury?

Difficulty using both sides of the body together 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?

Difficulty remembering things seen Yes No Prior to Injury?

Difficulty remembering names or words Yes No Prior to Injury?

Difficulty with numbers Yes No Prior to Injury?

Dislike heights Yes No Prior to Injury?

Why do you feel the need for a vision evaluation?

Do you feel your vision interferes with activities of daily living? Yes No

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

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?

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 or near activities?

How many hours daily are spent on a computer?

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

I authorize the release of medical information to other health care providers or insurance carriers upon their written request, or upon the recommendation of the Hollywood Vision Center - Optometry when it is necessary for the treatment of my visual condition or for the processing of insurance claims. This authorization shall be considered valid for the duration of my treatment. Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us to perform a more comprehensive evaluation and to better meet your specific visual needs. If at any time you have any questions or concerns regarding your vision or treatment, please do not hesitate to contact us. We request a minimum of 24 hours notice if you are unable to keep this appointment. Please be on time for your evaluation so that we may have the maximum opportunity to evaluate your visual status. Your visit can take from one (1) hour to (2) two hours.

Our office cannot provide you with information regarding the extent of coverage by your insurance company. All we can do is get an estimate based on information that we gather from you and/or your insurance company’s website. We are out-of-network for most major medical carriers. Please be prepared to pay for your services and materials at the time of your visit. If you have any questions, please contact our office.

Signature of patient or authorized representative

Date

Learn More

Vision Rehabilitation Questionnaire

General Information

Medical History

Initial Treatment

Subsequent/Other Professional Care

Medical History

Visual History

Do you currently experience any of the following:

Lifestyle

Employment/Education Information (If Applicable)

Release of Information and Insurance Filing:

Payment for Services: