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Home » Contact Us » Patient Forms » Adult History Form Vision Therapy

Adult History Form Vision Therapy

Adult History Form

Patient’s Name:(Required)

First Last

Goes by:

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 SITUATION

Why 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 HISTORY

List any illnesses, seizures, accidents, surgeries, fevers, etc

Illness/Injury

Age

Severity

Complications (if any)

List any prescription or over-the-counter medications being taken, dosage, reason

Untitled Survey Field

Excellent	Good	Fair	Poor

Health at the present time:

Do you suffer from any chronic problems (asthma, colds, allergies, ear infections)?

VISUAL HISTORY

When 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:

Name

Age

Visual Condition

Treatment

List any complications or abnormalities surrounding your mother’s pregnancy and your birth

List any developmental delays as a child (crawling, walking, etc.)

EDUCATIONAL HISTORY

Highest 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 HOBBIES

What 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.

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Advanced Eye Center

5151 Bluebonnet Blvd
Baton Rouge, LA 70809

Phone: 225-769-6010
Email: frontdesk@advancedeyecenter.com
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 5:30 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: Closed
Saturday: Closed
Sunday: Closed

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Advanced Eye Center
5151 Bluebonnet Blvd
Baton Rouge, LA 70809
Phone: 225-769-6010
https://www.advancedeyecenter.com

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