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Vision Rehabilitation Online Questionnaire

Vision Rehabilitation Online Questionnaire

Please carefully complete our questionnaire. This form does not need to be printed, once submitted, we should receive it on our end. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your visual system related to your specific needs.

48 Hour Cancellation Policy

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill other patient’s scheduling needs and keeps the clinic operating at is most efficient level. Due to our 60-minute exams missed appointments are a significant inconvenience to your doctor, the clinic and other patients.

This policy is in place out of respect for our doctors and our clients. Cancellations with less than 48 hours notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot and leave a 60-minute hole in the doctor’s schedule.

Please provide our office with 48-hour notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 48-hour notice to change a scheduled appointment will be responsible for a $350 service charge. This charge cannot be billed to insurance and must be paid before scheduling your next appointment.
We reserve your one-hour appointment time just for you. We do not double-book our patients so that we may provide optimum treatment outcomes for all our patients. 48-hour notice allows us to offer that time to a wait-listed patient.

NOTE: You will never be charged for a cancellation if it is made more than 48 hours in advance of your scheduled appointment time.

Thank you for providing our office and our patients with this courtesy.

Sincerely,

Drs. Garbus & Benosa, and the Family Vision Care Staff

How did you hear about our office

If referred by professional, please select type

Name of Referral

Referral's Phone Number

General Information

First Name*

Last Name*

Gender

Male Female

Birth Date*

Street Address (with apartment #)*

City*

State *

Zip Code*

Phone Number #1 *

Type *

Phone Number #2

Type

Phone Number #3

Type

Do you have Major Medical Insurance?

Yes No

If yes, who is the carrier?

Policy Number

Does the insurance cover eye examinations or glasses?

Yes No

Primary Insurance

Policy Number

Secondary Insurance

Policy Number

Social Security Number

Occupation

Employer

Spouse's Name

Spouse's Cell Phone Number

Medical History

Date of injury/accident

Type of injury/accident

If other, please explain.

What part of your head was affected? Check all that apply

Forehead Ride Side Left Side Back of Head Top of Head Face

Was your injury Open Head (bleeding) or Closed Head (non-bleeding)?

Open Head Closed Head

Did you lose consciousness?

Yes No

If yes, for how long?

If other, please explain.

Initial Treatment

When did you first see a doctor regarding your accident/injury?

Name of Doctor

Specialty

Where were you seen?

Were you hospitalized?

Yes No

If yes, for how long?

What were you and your family told?

What did the initial treatments consist of?

What prognosis/recommendations were you given?

Were you given any medications? If you were, what was it and what was it for?

Please list current medications with their dosage and reason.

Subsequent/Other Professional Care

What types of professional care have you received or are you currently receiving?

Name of Physician

Date of Late Visit

Address

City

Zip Code

Name of Physiatrist

Date of Last Visit

Address

City

Zip Code

Name of Neurologist

Date of Last Visit

Address

City

Zip Code

Name of Neurophysiologist

Date of Last Visit

Address

City

Zip Code

Name of Physical Therapist

Date of Last Visit

Address

City

Zip Code

Name of Speech/Language Therapist

Date of Last Visit

Address

City

Zip Code

Name of Psychologist

Date of Last Exam

Address

Medical History

City

Zip Code

Name of Osteopathic Physician

Date of Last Visit

Address

City

Zip Code

Name of Occupational Therapist

Date of Last Visit

Address

City

Zip Code

Name of Optometrist or Opthalmologist

Date of Last Visit

Address

City

Zip Code

Do you have a history of allergies?

Yes No

If you have any allergies, please list them.

Has a neurological evaluation been performed?

Yes No

If yes, by whom?

When was the evaluation performed?

What were the results?

Has a psychological evaluation been performed?

Yes No

If yes, by whom?

When was the evaluation performed?

What were the results?

Has a speech and language evaluation been performed?

Yes No

If yes, by whom?

When was the evaluation performed?

What were the results?

Vision History

Do you currently, or have you ever had any problems in the following areas?

Loss of Vision

Yes No

Explain

Blurred Vision

Yes No

Explain

Distorted Vision/Halos

Yes No

Explain

Loss of Side Vision

Yes No

Explain

Dryness

Yes No

Explain

Mucous Discharge

Yes No

Explain

Redness

Yes No

Explain

Sandy or Gritty Feeling

Yes No

Explain

Itching

Yes No

Explain

Burning

Yes No

Explain

Foreign Body Sensation

Yes No

Explain

Excess Tearing/Watering

Yes No

Explain

Glare/Light Sensitivity

Yes No

Explain

Eye Pain or Soreness

Yes No

Explain

Chronic Infection of Eye or Lid

Yes No

Explain

Sties or Chalazion

Yes No

Explain

Flashes/Floaters in Vision

Yes No

Explain

Tired Eyes

Yes No

Explain

Have you had a previous vision evaluation?

Yes No

If yes, by whom?

Reason for Last Exam

Which was prescribed last eye exam?

Glasses Contact Lenses Nothing

Are they used?

Yes No

If yes, when? If not, why not?

Were there any additional tests, treatments, or therapies recommended concerning your vision?

Yes No

If yes, what?

Did you undergo these treatments?

Yes No

Explain

Why do you feel the need for a vision evaluation?

Review of Systems

Do you use tobacco products?

Yes No

If yes, what type, how much, and how long?

Do you consume alcohol?

Yes No

If yes, what type, how much, and how long?

Do you currently, or have you ever had any problems in the following areas? If you do, please explain.

Integumentary (Skin)

Yes No

Explain

Headaches

Yes No

Explain

Migraines

Yes No

Explain

Seizures

Yes No

Explain

Allergies

Yes No

Explain

Hay Fever

Yes No

Explain

Sinus Congestion

Yes No

Explain

Runny Nose

Yes No

Explain

Post-Nasal Drip

Yes No

Explain

Chronic Cough

Yes No

Explain

Dry Throat/Mouth

Yes No

Explain

Cold Sores

Yes No

Explain

Asthma

Yes No

Explain

Chronic Bronchitis

Yes No

Explain

Emphysema

Yes No

Explain

Tuberculosis

Yes No

Explain

Diabetes

Yes No

Explain

Heart Pain

Yes No

Explain

High Blood Pressure

Yes No

Explain

Vascular Disease

Yes No

Explain

Genitals

Yes No

Explain

Kidney

Yes No

Explain

Bladder

Yes No

Explain

Venereal Disease

Yes No

Explain

Syphilis

Yes No

Explain

Gonorrhea

Yes No

Explain

Rheumatoid Arthritis

Yes No

Explain

Muscle Pain

Yes No

Explain

Joint Pain

Yes No

Explain

Anemia

Yes No

Explain

Bleeding Problems

Explain

HIV

Yes No

Explain

Endocrine (Thyroid/Other Glands)

Yes No

Explain

Psychiatric

Yes No

Explain

Cancer

Yes No

Explain

Family History

If anyone in the family (grandparents, uncles, aunts, cousins, mother, father, and/or siblings) has any of the following conditions, please indicate who. If not applicable, please leave it blank.

Amblyopia

Arthritis

Blindness

Brain Tumor

Cancer

Cornea Problems

Corneal Transplant

Crossed/Lazy Eye

Detached Retina

Diabetes

Epilepsy/Seizures

Glaucoma

Heart Problems

High Blood Pressure

Keratoconus

Kidney Problems

Learning Disability

Macular Degeneration

Multiple Sclerosis

Stroke

Tuberculosis

Thyroid Condition

Traumatic Brain Injury

Lifestyle

Do you feel your vision interferes with activities of daily living?

Yes No

If yes, please explain (include effects involving home, work and hobbies, social and personal relationships.)

What activities comprise the majority of your daily life since your accident/injury?

What activities can you no longer engage in due to your visual or other difficulties?

What other changes/limitations in your daily life do you attribute to your accident/injury?

What do you hope a Visual Rehabilitation Program can do for you?

Employment/Education Information

Please answer the following if applicable.

What is your current employment position?

If a student, what is your major course of study?

How many hours daily are spend working at distance?

How many hours daily are spent reading/studying?

How many hours daily are spent on a computer?

Vision Rehabilitation Checklist

Please assign a value between 0 and 4 for each symptom. 0 is Never or Non-existent, 1 is Occasionally (1-2 times per month), 2 is Often (1-2 times every two weeks), 3 is Frequently (3-5 times per week), 4 is Always Happens. Also check off if the symptom existed prior to your injury/accident.

Double vision at distance

0 2 3 4 Existed Prior to Injury/Accident

Double vision at near