• VISION REHABILITATION QUESTIONNAIRE

    Please return the questionnaire at least 2 business days prior to your evaluation to info@optimeyes.com.au
  • Personal Details:

  • Occupation?

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  • Have you been referred? Who do we thank for your referral ?

  • MEDICAL HISTORY

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

  • If yes, for how long? 

  • If yes, how long? 

  • Other: 

  • INITIAL TREATMENT

  • When did you first see a doctor regarding your accident/injury?      
    Name of Doctor:       Specialty:            
    Where were you seen?      
    Were you hospitalised?          
    How long for?      
    What were you and your family told?       
    What did the initial treatments consist of?       
    What prognosis/ recommendations were you given?         
    Were you given medications?         
    Medication?      
    For what conditions?      
    Any supplements or medications used currently?      

  • Subsequent/Other professional care

    What types of professional care have you received or are you currently receiving? Check which apply and expand.
  • Name:      
          Name:      
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       Name:      
     Name:    
     Name:   
       Name:        
         Name:      
       Name:      
              
    Other?      
              

  • Medical and Family History

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  • Visual History

  • Have you had a previous vision evaluation?         
    Optometrist's name      Date of last visit   Pick a Date   
    Reason for the visit      
    Results and recommendations      
    Were glasses, contact lenses, or other optical devices prescribed or recommended?
    If so, what?        
    If you wear contact lenses, how long have you worn?      
    What type of lenses do you have (i.e. hard, soft, gas-permeable)?      
    Which solutions do you use?       
    Were any additional tests, treatments or therapies recommended concerning your vision?         
    Did you undergo these treatments?                           
    Comments?      

  •  
  • What do you hope to gain from today's evaluation?

  • Lifestyle

  • Please expand

  • Are there any changes limitations in your daily life you attribute to your accident/injury? 

  • Employment/education information (if applicable)

  • What is current employment position? 

  • If a student, what is the major course of study?  

  • How many hours daily are spent at a desk?

  • How many hours daily are spent working at near distance?

  • How many hours daily are spent reading/studying?

  • How many hours daily are spent with a computer?

    Thank you for completing the questionnaire. The information will allow for more efficient use of time and will enable us to perform a more comprehensive evaluation. If you have any questions prior to your consultation, please do not hesitate to ask Should you need to cancel the appointment please note that we respectfully request 24 hours’ notice to avoid cancellation fees. I look forward to seeing 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.

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  • 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.

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  • 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.

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  • Should be Empty: