Adult History Form Vision Therapy Adult History FormPatient’s Name:(Required) First Last Goes by: Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:(Required)Cell Phone:Date of Birth:(Required) MM slash DD slash YYYY (Required) Male Female Email Address:(Required) Occupation: Spouse’s Name: Spouse’s Name: Spouse’s Occupation: Spouse’s Cell Phone:How did you hear about our office? PRESENT SITUATIONWhy do you wish to be evaluated? List any complaints you have concerning your vision: At what age did the problem begin? Under what circumstances? Has the problem become better or worse? Explain Does anyone else in the family have a similar problem? Has there been any previous treatment? MEDICAL HISTORYList any illnesses, seizures, accidents, surgeries, fevers, etcIllness/InjuryAgeSeverityComplications (if any) Add RemoveList any prescription or over-the-counter medications being taken, dosage, reason Untitled Survey FieldExcellentGoodFairPoorHealth at the present time:Do you suffer from any chronic problems (asthma, colds, allergies, ear infections)? VISUAL HISTORYWhen was your last eye exam? MM slash DD slash YYYY Clinic Name: Clinic Address: Street Address Address Line 2 City State / Province / Region Were glasses recommended or prescribed? Were treatment recommendations made? Yes No explain: Was the treatment plan followed (if applicable)? Was the treatment plan effective (if applicable)? Has Vision Therapy ever been recommended? Yes No has the program been completed? List any family members who have had vision treatment:NameAgeVisual ConditionTreatment Add RemoveList any complications or abnormalities surrounding your mother’s pregnancy and your birth List any developmental delays as a child (crawling, walking, etc.) EDUCATIONAL HISTORYHighest grade completed in school: Did you enjoy school? Specifically describe any school difficulties you experienced: Do you like to read? What do you enjoy reading? Would you rather be read to than read by yourself? Have you ever been classified ADD, ADHD, LD, dyslexic or any other diagnosis? If yes, which one(s)? Are you taking any medication for any of these conditions? List any psychological or educational tests performed: INTERESTS AND HOBBIESWhat hobbies or activities do you most enjoy? (art, music, etc.) What hobbies or activities do you least enjoy? Are you involved in any organized sports activities or teams? Yes No what? Do you enjoy music? Do you play a musical instrument? Yes No what? Can you carry a tune? Can you maintain rhythm when dancing? Briefly describe your personality. CAPTCHA