SPEED™ Questionnaire Adult Amblyopia & Strabismus Questionnaire 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* Date Format: MM slash DD slash YYYY AgePrimary Phone Number*Secondary Phone NumberEmail* Appointment Location*Progressive Optometry (Panorama) 34 Panatella Blvd NWBrowz Eyeware (Bridgeland) #5, 1010 1st Ave NEAny location: first available appointmentPlease indicate which location your appointment is booked at/ or which location you would like your appointment scheduledOccupationWhom may we thank for referring you to our office?Chief Complaint/Primary Reason*Medical HistoryDate of most recent medical exam Date Format: MM slash DD slash YYYY Doctor’s nameReasonResultsList any medicationsList 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)?YesNoAny current or past Occupational, Physical and/or Speech Therapy (please circle)?YesNoVisual HistoryIs there any history of the following?SelfFamilyEye Turn/StrabismusLazy Eye/AmblyopiaHigh PrescriptionLearning DisabilitiesEye Shake/NystagmusADD/ADHDAny other visual conditions?Date of last eye exam Date Format: MM slash DD slash YYYY Results & RecommendationsWere glasses prescribed from last eye exam?YesNoDid you fill the prescription?YesNoAge of current glassesAre they worn full or part time?YesNoFor near or distance ?Have you worn an eye patch to treat lazy eye?YesNoHow often and for long was it done?Past eye surgery? WhenWhich EyeSurgeonDo 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?YesNoWork HistoryHow many hours are you on the computer?How does your vision affect your job?Please assign a value between 1 and 4 for each symptomNeverSeldomFrequentlyAlwaysDouble visionBlurred vision at nearHead tilt or closing one eye when readingHeadaches associated with near workWords run together when readingFalling asleep when readingVision worse at the end of the dayPoor ability to remember what is readSkipping words/lines when readingAvoiding sports and gamesInability to estimate distances accuratelyDifficulty copying from chalkboardHolding reading material too closeA report will be written soon after the examination. Would you like our office toEmail you a report. Yes Fax a copy. Yes Please provide email address: Please provide your fax number:
