Sports Vision Questionnaire Please fill out this questionnaire carefullyName First Last AgeDate of Birth Date Format: MM slash DD slash YYYY Email Address Main Concerns/Reason for visitWhom may we thank for referring you to our office?Sport# of hours playing sport(s) each dayTeam/Club InfoCoach/Athletic Trainer(s)MEDICAL HISTORYDate of most recent medical exam Date Format: MM slash DD slash YYYY Doctor’s nameReasonResultsHave you had a sports injury in the last year?YesNoPlease explainHave you had a concussion?YesNoHow many, when and howList illnesses, bad falls, high fevers, car accident, etc List any chronic problems (ie. ear infections, asthma, allergies) List any medications currently using (including vitamins and supplements) Is there any history of the following?Self Eye Turn/Strabismus Colour Blindness Learning Disabilities Lazy Eye/Amblyopia Eye Shake/Nystagmus ADD/ADHD High Prescription Glaucoma Seizures Family Eye Turn/Strabismus Colour Blindness Learning Disabilities Lazy Eye/Amblyopia Eye Shake/Nystagmus ADD/ADHD High Prescription Glaucoma Seizures VISUAL HISTORYDate of last eye exam Date Format: MM slash DD slash YYYY Name of previous eye doctorReason for examResults and recommendationsDo you wear glasses for driving sports television computer reading Age of first spectacleDo you feel glasses or contacts are ideal for your sport?YesNoPlease explainIf you wear contacts, what kind?Hours of wearing time?If you do not wear contacts, are you interested in wearing them?YesNoAny eye injuries or eye surgeries? When and describeDo you feel your vision is affecting your sports performance?YesNoPRESENT SITUATIONDo you experience any of the following? Intermittent blurry vision at distance Intermittent blurry vision at near Red / Burning eyes Itchy eyes Watery eyes Eyes Strain / Tired Headaches around forehead, temple or eyes Nausea associated with visual tasks Starburst or halos around lights Double vision at distance Double vision at near Squinting, covering or closing one eye Sensitivity to light Sensitivity to lighting Sensitivity to glare If yes, when?SPORTSWhat position(s) do you play?What hand do you throw with?RLBoth If applicableWhich way do you bat/swingRLSwitchWhich foot do you kick with?RLBoth If applicableWhich eye do you sight with?RLDo you have any visual plan when or before you compete?YesNoDo you do any visual warm up activities?YesNoDo you have any problems with balance?YesNoIs your overall sports performance as consistent as you would like?YesNoIs the level of your performance consistent throughout a game?YesNoDoes your performance decrease under pressure?YesNoDoes your performance increase under pressure?YesNoDoes any of the following interfere with or affect your performance? (Check all that apply) bright sun dim light without sunglasses with sunglasses busy background crowd movement player movement crowd noise rain uniform colour Do you feel you are playing at your potential?YesNoPlease describeWhat areas would you like to improve? Tracking Visualization Concentration Reaction Time Depth Perception Attentional Focus Peripheral Awareness Judging Distance Consistency in Performance Eye-Hand Coordination Judging Speed Decreasing Distractibility If not listed above, list any specific areas you would like to improve in your game Additional comments you would like us to know