(661) 775-1860

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(661) 775-1860

Home New Patient Forms Supplemental Strabismus Online Questionnaire

Supplemental Strabismus Online Questionnaire

This form is to be filled out in addition to a general adult or child questionnaire which can be found under the new patient forms tab. Please fill out the questionnaire carefully and as thoroughly as possible.

General Information

Patient's Name

Gender Male Female

Birth Date

Phone

Street Address (with apartment number)

City

Zip Code

Medical History

Is there any history in your family of an eye turn resulting from a disease or other condition? Yes No

If Yes, Please Explain

Was there any related trauma, disease, or condition that preceded or accompanied the onset of your eye turn? Yes No

If yes, please explain.

Are you prone to infection? Yes No

Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No

Has a neurological evaluation been performed? Yes No

By whom?

Results and recommendations

Has a psychological evaluation been performed? Yes No

By whom?

Results and recommendations

Has an occupational therapy evaluation been performed? Yes No

By whom?

Results and recommendations

Nutritional Information

How is your current diet? Excellent Good Fair Poor

Do you like or crave sweets? Like Crave

Are there any indications that you have been exposed to any toxic substances or fumes? Yes No

If so, please explain.

Visual History

At what age was it first noticed or suspected that there was an eye turn?

Did the eye begin turning suddenly or gradually? Suddenly Gradually

Does the eye turn in, out, up, or down? (Check all that apply) In Out Up Down

Is the eye turn getting worse or better or is there no change? Worse Better No Change

Is it always the same eye that turns? Yes No

If yes, which eye? Right Left

Is the eye turn always present? Yes No

If no, under what conditions is it present?

Does the eye always turn the same amount? Yes No

If no, please explain.

Do you notice the eye turn more when you look up close? Yes No

Do you notice the eye turn more when you look in the distance? Yes No

Do you notice the eye turn more when you look to the left? Yes No

Do you notice the eye turn more when you look to the right? Yes No

Do you notice the eye turn more when you look up? Yes No

Do you notice the eye turn more when you look down? Yes No

Does one pupil ever appear to be larger than the other? Yes No

Do you ever notice one or both eyes shaking rapidly? Yes No

Do you feel the vision hinders you from daily activities in any way? Yes No

If yes, how?

Please list any other visual complaints.

Previous Treatments

Does the eye turn less when glasses, contacts, or a prescribed optical device is worn? Yes No Unsure

Has there been any treatment using an eye patch? Yes No

If yes, please describe when the patching was started, how the patching is done, including the age it started, the eye patched, the duration of treatment, and an estimate of the result.

Has there been any surgical treatment? Yes No

If yes, please describe the surgery, including the age surgery was performed, the number of operations, the eye(s) operated on, and an estimate of the cosmetic and subjective results.

Were you satisfied with the results of surgery? Yes No

Explain

Was the surgeon satisfied with the results of surgery? Yes No

Explain

Are you here for a second opinion regarding surgery or further treatment? Yes No

Has there been any visual therapy? Yes no

If yes, with what doctor?

Please describe the type of visual therapy, including duration, the age at which it started and an estimate of results.

Is there any other information that you feel would be helpful or important in our evaluation and/or treatment?

Lifestyle Checklist

Please assign a value between 0 and 4 for each symptom. 0 is Never or Non-existent, 1 is Occasionally, 2 is Often, 3 is Frequently, 4 is Always. If this was completed in a previous child questionnaire, please continue to the end and submit this questionnaire.

Blurred vision

Double vision

Eyes hurt

Eyes tired

Headaches associated with near work

Words run together when reading

Burning, stinging, watery eyes

Falling asleep when reading

Frequent eye rubbing

Eyes frequently reddened

Skipping or repeating lines when reading

Words move around on page when reading

Dizziness or nausea associated with near work

Head tilt or closing one eye when reading

Avoidance of reading or near work

Omitting small words when reading

Writing uphill or downhill

Maligning digits in columns of numbers

Reading comprehension declining over time

Inconsistent or poor sports performance

Holding reading material too close

Short attention span

Difficulty completing assignments in reasonable time

Saying "I can't" before trying

Difficulty with hand tools (scissors, screwdrivers, keys, etc.)

Reverses letters or words

Tendency to knock things over on desk or table

Motion sickness or car sickness

Difficulty with time management

Difficulty with money concepts and/or making change

Misplaces or loses papers/objects, forgetful, poor memory

Reads slowly

Uses finger as marker to read

Bothered by light

Frequent blinking

Confuses right and left

Glum, sulky, moody, bad temper

Please do not submit any Protected Health Information (PHI).

Location

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Family Vision Care Optometry INC.

Contact Information

Phone: (661) 775-1860

Fax: (661) 775-9627

Email: customercare@fvcoptometry.net

Address

28089 Smyth Dr
Valencia, CA 91355

Hours of Operation

Monday

09:00 am - 06:00 pm

Tuesday

09:00 am - 06:00 pm

Wednesday

09:00 am - 06:00 pm

Thursday

09:00 am - 06:00 pm

Friday

09:00 am - 06:00 pm

Saturday

Closed

Sunday

Closed

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