optimeyes.com.au-VISION REHABILITATION QUESTIONNAIRE

VISION REHABILITATION QUESTIONNAIRE

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

Address

Street Address Line 2
Email
example@example.com
Phone
Mobile
Occupation?
blanks
Birth Date

Month Day Year
Date
Medicare Number
10 digit number
Ref #
the number next to your name
Exp Date

Month Day Year
Exp Date
Private Health Fund?
Private Health fund membership number
Ref #
the number next to your name
Have you been referred? Who do we thank for your referral ? blanks
MEDICAL HISTORY
Date of injury/accident:
Type of injury/accident:

Motor vehicle Fall Blow to head Industrial Accident Medication related Drug abuse Poison or toxic substance Carbon dioxide Drowning Cord around neck Stroke Aneurysm Haemorrhage Other
What part of your had was affected? {check all that apply):

Forehead Right side Left side Back of head Top of head Face
Was the injury OPEN HEAD (bleeding) or CLOSED HEAD (non-bleeding)? blanks
Did you lose consciousness?

Yes No
If yes, for how long? blank
Were you in a coma?

Yes No
If yes, how long? blank
Symptoms immediately following the accident/injury: (check all that apply)

Double vision Headache Blurred vision Pain in or around eyes Dizziness Vomiting Flashes of light Disorientation Loss of balance Neck pain/whiplash Loss of memory Restricted field of view Restricted motion
Other: blanks
INITIAL TREATMENT
When did you first see a doctor regarding your accident/injury?
Name of Doctor:       Specialty:
Where were you seen?
Were you hospitalised?    Yes   No
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?   Yes   No
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.
Physician Name:
Neurologists      Name:
Neuropsychologist   Name:
Physiotherapist   Name:
Physical therapist Name:
Speech/language therapist Name:
Psychologist/Psychiatrist   Name:
Osteopath      Name:
Chiropractor   Name:

Other?
Medical and Family History

Please indicate if there is a history of the following.

	Self	Family	Who
Diabetes
Multiple Sclerosis
Blindness
Glaucoma
High Blood Pressure
Strabismus crossed eye
Amblyopia /lazy eye
Thyroid Condition
Cataracts
Macular Degeneration
Other, please state

Visual History
Have you had a previous vision evaluation?   Yes   No
Optometrist's name      Date of last visit   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?   Yes   No
Did you undergo these treatments?   Yes   No
Comments?

Do you experience any of the following?

	Yes	No	Prior to injury
Eyes ache
Eyes pull or tug
Difficulty moving or turning eyes
Pain with movement of eyes
Eyes twitch
Pain in and around eyes
Redness
Double Vision at distance
Double vision at near
One eye turns in, out, up or down
Squinting, covering or closing an eye
Bright light is bothersome
Fluorescent light is bothersome
Patterned wallpaper and carpets are bothersome
Headaches
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
Moves head when reading
Skip lines when reading
Words more or jump around when reading
Omission of words when reading / copying
Head moves when reading
Use of finger to keep place
Avoids close work
Difficulty with peripheral vision
Objects jump in and out of field of view
Motion / car sickness
Reduced depth perception
Tunnel vision/Loss of visual field
Flashes of light
Difficulty dressing/bathing/hygiene
Difficulty following directions
Bothered by noise
Bothered by touch
Difficulty remembering things seen
Difficulty remembering things heard
Difficulty remembering names
Difficulty remembering formerly familiar people/objects
Difficulty with numbers
Difficulty with money
Poor time management

What do you hope to gain from today's evaluation? blanks
Lifestyle
Do you feel your vision interferes with any aspects of your daily living?

Yes No
Please expandblanks
Are there any changes limitations in your daily life you attribute to your accident/injury? blanks
Employment/education information (if applicable)
What is current employment position? blanks
If a student, what is the major course of study? blanks
How many hours daily are spent at a desk?blanks
How many hours daily are spent working at near distance?blanks
How many hours daily are spent reading/studying?blanks
How many hours daily are spent with a computer?blanks

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.
Signature

Clear
Date

Month Day Year
Date
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

Month Day Year
Date
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

Month Day Year
Date
Should be Empty:

VISION REHABILITATION QUESTIONNAIRE

Personal Details:

MEDICAL HISTORY

INITIAL TREATMENT

Subsequent/Other professional care

Medical and Family History

Visual History

Lifestyle

Employment/education information (if applicable)