Please fill out this questionnaire carefully

Name

First Last

Age

Date of Birth

Email Address

Main Concerns/Reason for visit

Whom may we thank for referring you to our office?

Sport

# of hours playing sport(s) each day

Team/Club Info

Coach/Athletic Trainer(s)

MEDICAL HISTORY

Date of most recent medical exam

Doctor’s name

Reason

Results

Have you had a sports injury in the last year?

Yes
No

Please explain

Have you had a concussion?

Yes
No

How many, when and how

List 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 HISTORY

Date of last eye exam

Name of previous eye doctor

Reason for exam

Results and recommendations

Do you wear glasses for

driving
sports
television
computer
reading

Age of first spectacle

Do you feel glasses or contacts are ideal for your sport?

Yes
No

Please explain

If you wear contacts, what kind?

Hours of wearing time?

If you do not wear contacts, are you interested in wearing them?

Yes
No

Any eye injuries or eye surgeries? When and describe

Do you feel your vision is affecting your sports performance?

Yes
No

PRESENT SITUATION

Do you experience any of the following?

If yes, when?

SPORTS

What position(s) do you play?

What hand do you throw with?

R
L
Both If applicable

Which way do you bat/swing

R
L
Switch

Which foot do you kick with?

R
L
Both If applicable

Which eye do you sight with?

R
L

Do you have any visual plan when or before you compete?

Yes
No

Do you do any visual warm up activities?

Yes
No

Do you have any problems with balance?

Yes
No

Is your overall sports performance as consistent as you would like?

Yes
No

Is the level of your performance consistent throughout a game?

Yes
No

Does your performance decrease under pressure?

Yes
No

Does your performance increase under pressure?

Yes
No

Does any of the following interfere with or affect your performance? (Check all that apply)

Do you feel you are playing at your potential?

Yes
No

Please describe

What areas would you like to improve?

If not listed above, list any specific areas you would like to improve in your game

Additional comments you would like us to know

Sports Vision Questionnaire

MEDICAL HISTORY

VISUAL HISTORY

PRESENT SITUATION

SPORTS

Bridgeland (Browz Eyeware)

Panorama Hills (Progressive Optometry)

Douglasdale – South Trail Crossing

Macleod Trail