Please fill out this questionnaire carefully. Thank you.

Patient’s Name*

First Last

Age

Date of Birth*

Parent/Guardian's Name

First Last

Whom may we thank for referring you to our office?

Primary Phone Number*

Secondary Phone Number

Email*

Appointment Location*

Please indicate which location your appointment is booked at / or which location you would like your appointment scheduled.

Occupation

Chief Complaint*

When did it start?

MEDICAL HISTORY

Date of most recent medical exam

Doctor’s name

Reason/results

List any medications

List any bad falls, head injuries, car accidents and/or stroke, and year of occurrence

List any chronic problems

Has a neurological and/or psychological evaluation been performed

Yes
No

By whom/Results?

Any current or past Occupational, Physical and/or Speech Therapy

Yes
No

By whom/Results?

Is there any history of the following?

Other visual conditions

VISUAL HISTORY

When and who performed your the last eye exam:

If you wear glasses, please answer the questions below.

Age of glasses #1

Are they:

Progressive
Distance
Computer
Reading
Prescription Sunglasses

Any concerns with them?

Age of glasses #2

Are they:

Progressive
Distance
Computer
Reading
Prescription Sunglasses

Any concerns with them?

Age of glasses #3

Are they:

Progressive
Distance
Computer
Reading
Prescription Sunglasses

Any concerns with them?

If you wear contact lenses, please write the brand and power of the lenses.

Have you worn “binasal occlusion” where tape is applied to inner part of your glasses?

Yes
No

Past eye surgeries?

Date

Type

Which Eye

Surgeon

Date

Type

Which Eye

Surgeon

If you have double vision, please answer the questions below.

When did it start?

Is the double image(please circle): side by side, diagonal, up and down or it varies in direction?

Is the double vision occurring when looking at near or far distance?

When does it occur? morning, night, driving, reading, computer, all day

Does the double image disappear if you close one eye?

Yes
No

Does your glasses help eliminate your double vision?

Traumatic Brain Injury & Post Concussion Syndrome

Symptom Survey

(Please fill out information below here)

Patient:

Age

Date of Injury:

Cause of Injury:

Location of Head injury

#1 Symptom

#2 Symptom

	0	1	2	3	4	5
Blurry Vision in the distance
Blurry Vision when reading
Fluctuating/inconsistant vision
Headaches
Photophobia (light sensitivity)
Phonophobia (hearing sensitivity)
Double vision
Loses place while reading
Words appear to run together when reading
Poor Memory, forgetful
Attention/Concentration difficulties
Visual memory difficulty
Vision is worse at the end of the day
Rereads reading material in order to comprehend
Difficulty with eye tracking
Eye fatigue
Mental fatigue
Physical fatigue
Spatial disorientation
Night vision worse than day vision
Dizziness
Flashes of light
Irritability
Emotional distress/anxiety
Balance issues
Vertigo/Nausea
Car/motion sickness
Sleep disturbances
Disorganized
Walking difficulties
Poor depth perception

	Self	Family
Eye Turn/Strabismus
Macula degeneration
Reading disabilities
Lazy Eye/Amblyopia
Dry/Red Eyes
Glaucoma
Diabetes

TBI/Post Concussion Questionnaire

MEDICAL HISTORY

VISUAL HISTORY

Traumatic Brain Injury & Post Concussion Syndrome

Panorama Hills (Progressive Optometry)

Bridgeland (Browz Eyeware)

Macleod Trail

Douglasdale – South Trail Crossing