optimeyes - Adult Vision Questionnaire

ADULT VISION QUESTIONNAIRE
PERSONAL DETAILS
Title
Name *
Surname
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone

Area Code Phone Number
Mobile
Medicare Number *
10 digit number
Ref # *
the number next to your name
Exp Date *
Occupation
Birth Date

Day Month Year
Private Health Fund Name *
Private Health fund membership number *
Ref # *
the number next to your name
If you were referred whom do I have to thank ?
MEDICAL AND FAMILY HISTORY
GP's name
Address

Apt.

Street Address Line 2

City State / Province

Postal / Zip Code

Please list your medications and supplements

	Medications	Supplements
1
2
3
4
5
6

Please list any allergies

Please indicate a history of the following

	Self	Family	For self-please advise on current status/treatment
Diabetes
Multiple Sclerosis
Blindness
Glaucoma
High Blood Pressure
Strabismus crossed eye
Amblyopia /lazy eye
Thyroid Condition
Cataracts
Macular Degeneration
Head injury/concussion

Additional information
Have you had a previous vision evaluation?

Yes No
Optometrist's name
Date of last visit

Day Month Year
Results and recommendations
Are you under the care of an Ophthalmologist?

Yes No
What for?
Name of Dr.
List any surgery or treatment you have had with your Ophthalmologist
Do you wear glasses for?

Distance Near Both Computer Hobby
Any issues with your glasses?
Do you wear contact lenses?

Full time Sport Social Soft RGP Multifocal
Any issues with your contact lenses?
Which solutions do you use?
PRESENT SITUATION
Reason for today’s visit

Do you experience any of the following?

	Yes / No	When
Blurred distance vision
Blurred near vision
Red or itchy eyes
Burning eyes
Watery eyes
Sore or tired eyes
Headaches
Double Vision at distance
Double vision at near
Squinting, covering or closing an eye
Need for very bright light when reading
Need for very dim light when reading
Loss of interest or short attention span for close work
General or visual fatigue at the end of the day
Loss of place often when reading
Skip lines when reading
Repetition of letter or words when reading
Omission of words when reading / copying
Use of finger to keep place
Head moves when reading
Confusion of what is being seen or read
Falling asleep when reading
Silent vocalization/moving lips while reading
Motion / car sickness
Difficulty with reading comprehension
Comprehension decreases over time
Letters or words floating when reading
Difficulty aligning columns of numbers
Can respond better orally than in writing
Write or print poorly
Poor time management

Comments on any items above
COMPUTERS
Any fatigue during or after being on the computer?
Do you have any difficulties with your current glasseswhen using the computer?
HOBBIES / SPORTS
Do you have any hobbies or sports which have specific visual requirements?
Are your visual needs being met during these activities?

Yes No
If not why?
Thank you for completing this questionnaire. The information supplied will allow for more efficient use of time.

If you have any questions or concerns, please do not hesitate to get in touch. Should you need to cancel the appointment please note that I respectfully request 24 hours' notice to avoid cancellation fees.

I look forward to meeting you soon

Carolyn McIlvin

Optometrist

CONSENTS:

RELEASE OF INFORMATION

IT IS OFTEN BENEFICIAL TO EXCHANGE INFORMATION AND DISCUSS YOUR EXAMINATION RESULTS WITH OTHER PROFESSIONALS INVOLVED IN YOUR CARE. PLEASE SIGN BELOW TO AUTHORISE THIS EXCHANGE OF INFORMATION.

I give my consent to share any pertinent data from my examination with other health care providers/professionals. This authorisation shall be considered valid throughout the duration of treatment.
Signature

Clear
Date

Day Month Year
CONSENT TO PHOTOGRAPH

PLEASE SIGN BELOW TO AUTHORISE.

From time to time it may be necessary and useful to photograph you in order to obtain records of eye movements, body movements and the like. The records are for the express use of the optometrist and therapist to gauge and monitor change and progress. They will not be provided to any external sources without your prior consent.

I give my consent for me to be photographed if clinically necessary.
Signature

Clear
Date

Day Month Year
CONSENT TO MAKE BODY CONTACT

PLEASE SIGN BELOW TO AUTHORISE.

At times it may be necessary at times to guide you with prompts which may require either the optometrist or therapist to gently touching you. This will mostly be on the head, arm or leg and occasionally trunk or hips. This will usually be during therapy but may occur during the assessments. We will always check with you first.

I give my consent for the optometrist or therapist to make body contact with me if clinically necessary.
Signature

Clear
Date

Day Month Year
Should be Empty:

ADULT VISION QUESTIONNAIRE

PERSONAL DETAILS

MEDICAL AND FAMILY HISTORY

PRESENT SITUATION

COMPUTERS

HOBBIES / SPORTS

CONSENTS:

RELEASE OF INFORMATION

CONSENT TO PHOTOGRAPH

PLEASE SIGN BELOW TO AUTHORISE.

CONSENT TO MAKE BODY CONTACT