Please fill out this questionnaire carefully. Please bring the completed form with you on the day of the evaluation. Thank you.

Patient’s Name*

First Last

Date of Birth*

Age

Primary Phone Number*

Secondary Phone Number

Email*

Appointment Location*

Please indicate which location your appointment is booked at/ or which location you would like your appointment scheduled

Main Concerns/Reason for visit

Occupation

Whom may we thank for referring you to our office?

Chief Complaint/Primary Reason*

Medical History

Date of most recent medical exam

Doctor’s name

Reason

Results

List any medications

List illnesses, bad falls, head injuries, car accidents etc.

List any chronic problems (ie. asthma, allergies)

Has a neurological and/or psychological evaluation been performed (please circle)?

Yes
No

Any current or past Occupational, Physical and/or Speech Therapy (please circle)?

Yes
No

Visual History

Is there any history of the following?

Any other visual conditions?

Date of last eye exam

Results & Recommendations

Were glasses prescribed from last eye exam?

Yes
No

Did you fill the prescription?

Yes
No

Age of current glasses

Are they worn full or part time?

Yes
No

For near or distance ?

Have you worn an eye patch to treat lazy eye?

Yes
No

How often and for long was it done?

Past eye surgery? When

Which Eye

Surgeon

Do you have double vision? If yes, please answer the questions below.

When did it start?

Is the double image: side by side, diagonal, up and down or it varies in direction?

Is the double vision occurring at near, distance or both?

When does it occur? Morning, night, driving, reading, computer, all day?

Does the double image disappear if you close one eye?

Does your glasses help eliminate your double vision if any?

Yes
No

Work History

How many hours are you on the computer?

How does your vision affect your job?

Please assign a value between 1 and 4 for each symptom

	Never	Seldom	Frequently	Always
Double vision
Blurred vision at near
Head tilt or closing one eye when reading
Headaches associated with near work
Words run together when reading
Falling asleep when reading
Vision worse at the end of the day
Poor ability to remember what is read
Skipping words/lines when reading
Avoiding sports and games
Inability to estimate distances accurately
Difficulty copying from chalkboard
Holding reading material too close

A report will be written soon after the examination. Would you like our office to

Email you a report.

Yes

Fax a copy.

Yes

Please provide email address:

Please provide your fax number:

Additional comments you would like us to know

	Self	Family
Eye Turn/Strabismus
Lazy Eye/Amblyopia
High Prescription
Learning Disabilities
Eye Shake/Nystagmus
ADD/ADHD

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Medical History

Visual History

Work History

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