TBI/Post Concussion Questionnaire Please fill out this questionnaire carefully. Thank you.Patient’s Name* First Last AgeDate of Birth* Date Format: MM slash DD slash YYYY Parent/Guardian's Name First Last Whom may we thank for referring you to our office?Primary Phone Number*Secondary Phone NumberEmail* Appointment Location*Progressive Optometry (Panorama) 34 Panatella Blvd NWBrowz Eyeware (Bridgeland) #5, 1010 1st Ave NEAny location: first available appointmentPlease indicate which location your appointment is booked at / or which location you would like your appointment scheduled. OccupationChief Complaint*When did it start?MEDICAL HISTORYDate of most recent medical examDoctor’s nameReason/resultsList any medicationsList any bad falls, head injuries, car accidents and/or stroke, and year of occurrenceList any chronic problemsHas 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?SelfFamilyEye Turn/StrabismusMacula degenerationReading disabilitiesLazy Eye/AmblyopiaDry/Red EyesGlaucomaDiabetesOther visual conditionsVISUAL HISTORYWhen and who performed your the last eye exam:If you wear glasses, please answer the questions below.Age of glasses #1Are they: Progressive Distance Computer Reading Prescription Sunglasses Any concerns with them?Age of glasses #2Are they: Progressive Distance Computer Reading Prescription Sunglasses Any concerns with them?Age of glasses #3Are 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 Date Format: MM slash DD slash YYYY TypeWhich EyeSurgeonDate Date Format: MM slash DD slash YYYY TypeWhich EyeSurgeonIf 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 dayDoes the double image disappear if you close one eye? Yes No Does your glasses help eliminate your double vision?Traumatic Brain Injury & Post Concussion SyndromeSymptom Survey(Please fill out information below here)Patient:AgeDate of Injury:Cause of Injury:Location of Head injury#1 Symptom#2 Symptom012345Blurry Vision in the distanceBlurry Vision when readingFluctuating/inconsistant visionHeadachesPhotophobia (light sensitivity)Phonophobia (hearing sensitivity)Double visionLoses place while readingWords appear to run together when readingPoor Memory, forgetfulAttention/Concentration difficultiesVisual memory difficultyVision is worse at the end of the dayRereads reading material in order to comprehendDifficulty with eye trackingEye fatigueMental fatiguePhysical fatigueSpatial disorientationNight vision worse than day visionDizzinessFlashes of lightIrritabilityEmotional distress/anxietyBalance issuesVertigo/NauseaCar/motion sicknessSleep disturbancesDisorganizedWalking difficultiesPoor depth perception