Adult

Behavioral Optometry, Ltd.
5
Adult

Adult INTAKE FORM QUESTIONAIRE.

Step 1/7:

Leave this field blank

A) General information

Name *

Email *

Phone Number *

Date of Birth *

Appointment Date *

Appointment Time *

Handedness *

Left

Right

Referred By

Home Address (Please include City, State and Zip Code) *

Occupation

Your occupation *

Business phone

Spouse's Name

Spouse's Occupation

Brother/Sister (include DOB)

B) Signs of Vision Dysfunction

SIGHT is seeing clearly. 20/20 is just a measurement of sight or visual acuity/clarity.
VISION is taking in information, organizing it, and then doing something with it, i.e. perceiving, processing and performance. We separate visual perception, visual motor, visual auditory integration, visual-vestibular integration, visualization, eye movements, etc. from vision to understand vision, but they are all part of the overall process of vision directly governed or impacted by how we perceive, process and perform through our vision.

Please check all below that apply.

Difficulty with eye movements

Often loses place while reading or doing math problems

Prefers to touch things rather than just observe to gather information

Uses finger or marker to keep place when reading

Difficulty coordinating the information from each eye with thinking, movement, speaking and listening

Sensitive to or bothered by bright lights; will squint, cover eyes, eyes will water and/or get headaches

Difficulty concentrating in colorful rooms or dimly lit rooms

Prefers playing in the dark

Difficulty with consistent spacing and size of letters during writing

Rubs eyes, has watery eyes or gets headaches after reading or watching TV

Difficulty keeping eyes focused on task/activity he/she is working on for an appropriate amount of time

Easily distracted by other visual stimuli in the room, i.e. movement, decorations, toys, windows, etc.

Avoids eye contact

"See double”, i.e. words popping or moving off page, or words running together

Difficulty with consistent spacing and size of letters during writing

Tends to write at a slant (up or down hill) on a page

Messy/clumsy writing

Difficulty cutting/tracing along a lime

Difficulty lining up numbers in math problems

Fatigues easily with schoolwork, reading or computer reading tasks

Prefers learning auditorily instead of reading and/or studying

Poor reading comprehension skills

Rereads to understand

Slow reading

Difficulty judging spatial relationships in the environment, i.e., bumps into objects/ people or missteps on curbs or stairs

Difficulty with catching, throwing, hitting or kicking a ball

Poor timing at sports, e.g. when and where to catch or hit the ball

Mismatches in space, e.g. spills or knocks things over

Poor rhythm

Visual signs or symptoms indicating tunneling (One centers on a target or detail and ignores all other sensory input. This becomes more difficult to do under certain situations – tunneling in dynamic scenarios or multiple conversations leads to one becoming overwhelmed.)

Hard time seeing the “big picture”, i.e. focuses on the details or becomes sidetracked

Difficulty locating items among other items, i.e. papers on a desk, clothes in a drawer, items on a grocery shelf, toys in a box

Often loses place when copying from a book or whiteboard

Difficulty controlling eye movement to track and follow moving objects

Often unaware or inattentive to surroundings

Needs to be called several times to get attention when watching TV, playing video games, etc.

Goes off on tangents in conversations

Prefer playing and interacting with one to two others rather than a group

Poor organizational skills – loses things, poor planner, doesn’t put things away

Cannot find things in plain sight

Prefers individual sports, e.g. biking, hiking

Difficulty staying present in conversations, i.e. mind wanders

A step behind the action in team sports

Fragmenting (seeing the world in small chunks as opposed to the bigger picture)

Difficulty following multiple directions

Reads with pauses or hesitations, i.e. robotic manner

Lack of general fluidity, i.e. hesitations or pauses when doing sequential activities or movements

Signs and symptoms indicating visual perceptual/organizational inadequacies

Difficulty telling the difference between similar printed letters/figures, i.e. p & q, b & d, + & x or square & rectangle

Makes reversals in words or letters when copying, or reads words backwards, i.e. “was” for “saw” and “no” for “on” after first grade

Difficulty telling the difference between different colors, shapes and sizes

Difficulty finding differences in pictures, words, symbols or objects

Difficulty with jigsaw puzzles and copying shapes

Confuse spatial directions, e.g. left and right

Difficulty telling stories in proper sequence

Physical symptoms indicating visual distress

Complains of headaches with reading or computer tasks

General fatigue following reading, writing or computer tasks

Neck, shoulder or upper back tension

Eyes not fully open

Eye turn

Head tilts or turns during conversations (as opposed to looking directly at the person he/she is speaking to)

Head tilts or turns during reading or writing (as opposed to looking directly at the task)

Moves in closer to book when reading or writing (for children under 13 years the normal working distance is from the tip of the fist to the elbow, and for age 13+ the normal working distance is between 14-17 inches)

Grips pencil or pen tightly

Wobbly, off balance, or unsteady walking

Toe walker

Figure-ground issues indicating inadequate vision development

Sees the bigger picture but has difficulty recognizing their interrelationships

Overwhelmed with details

Often confused

Avoids dealing with details

Problems with visual memory and/or visualization

Poor spelling

Poor written expression, i.e. using various cognitive operations to translate ideas and thoughts into writing

Poor memory

Poor anticipation/thinking ahead skills

Difficulty applying concepts

C) Medical History

Most recent medical examination (please include doctors name and exam date)

Results from medical examination:

Medication(s) currently being taken and for what conditions:

Your current diet is nutritionally: *

Excellent

Good

Fair

Poor

Have you and/or your family experienced high blood pressure? *

My family

Both me and my family

Neither me or my family

Have you and/or your family experienced glaucoma? *

My family

Both me and my family

Neither me or my family

Have you and/or your family experienced diabetes? *

My family

Both me and my family

Neither me or my family

Have you recently suffered from:

Injury

Infection

Anoxia

Stroke

High fever

Transient blurred vision

Vertigo

Motion sickness

Chronic health problems due to glandular, metabolic or organic imbalances, toxic conditions or past traumatic event

General fatigue

Loss of visual system stamina

Loss of speed visual processing

Reduced peripheral vision

Light sensitivity

Tight fisted pencil grip

Gritted jaw

Inward turning feet

D) Visual History

Most recent eye examination (please include doctors name and exam date)

Reason for and results from from examination: *

Do you wear glasses or contact lenses?

Glasses

Contacts

Neither

If you answered yes to the above question, how often do you wear the glasses/contacts?

Please list family members who have needed visual attention and why:

E) Present Situation

Describe any indications of visual difficulty:

Do you feel your vision hinders your daily activities in any way?

Glasses

Contacts

Neither

If you answered yes to the above question, please explain:

Please check all that apply:

Can understand individual thoughts but have trouble understanding the whole concept or message

Can understand individual directions, but have trouble putting them together in order to initiate action based on those directions

Avoidance of reading/writing activities

Difficulty judging distances

Panic attacks when driving or in open spaces like malls/grocery stores

Orientation problems, e.g. poor sense of direction when driving or walking

Organizational problems both cognitively & physically e.g., poor planning, messy desk, messy rooms, etc.

Do you currently experience any of the following:

Eye aches

Eyes pull or tug

Difficulty moving or turning eyes

Pain with movement of eyes

Pain in or around eyes

Eye redness

Burning eyes

Watery eyes

Itchy eyes

Dry eyes

Eyes twitch

Motion sickness/car sickness

General headaches

Blurred vision at a distance

Blurred vision at near

Tunnel vision/ loss of visual field

Objects jump in and out of field of view

Dizziness

Frequent styes

Short attention span for reading/writing

Skip words frequently when reading

Movement of objects in the environment is bothersome

Fluorescent lights are bothersome

Patterned wallpaper or carpets are bothersome

Reduced depth perception

Loss of interest/concentration when doing close work

Orient writing/drawing poorly on page

Comprehension decreases the longer you read

Feel sleepy when reading

Trouble with spelling

Difficulty remembering what is read

Close eye or cover one eye

Dislike tasks requiring sustained visual attention

Feel nervous, irritable, restless or frustrated after sustaining concentration

Frequent blinking

Difficulty changing focus far to near

Distance blurs when looking up from close work

Eyes tire quickly when reading, sewing, cooking or doing computer work

Restless when doing desk work

Eye/body coordination activities (i.e. dancing) are difficult

Tailgate when driving

Trouble judging distance when parking/pulling into traffic

Frequently trip or stumble

Feel uncomfortable in crowded areas with a lot of movement

Comment on any of the above checked items:

F) Employment or School

Current position

Major course of study

How many hours per day are you sitting at a desk?

How many hours per day are you reading or studying?

How many hours per day are you working at a near distance?

How many hours per day are you sitting at a computer?

Are you achieving your potential at school/work?

Yes

Do you feel like you are getting adequate return for the amount of effort you put into a task?

Yes

If you answered yes to the above question, please explain:

Does your study/work course require comprehension of written words?

Yes

If you answered yes to the above question, please explain:

Briefly describe your activities at school/work:

G) Avocations

Describe what activities compromise the majority of your spare time:

Do you watch TV?

Yes

If you answered yes to the above question, about how many hours per day?

What is your average viewing distance from the TV?

Are you seriously involved in athletics?

Yes

Do you feel you are achieving your potential?

Yes

Of all the sports you have played, please list the ones you excel in:

Of all the sports you have played, please list the ones you do poorly in:

Adult

Adult INTAKE FORM QUESTIONAIRE.

A) General information

B) Signs of Vision Dysfunction

C) Medical History

D) Visual History

E) Present Situation

F) Employment or School

G) Avocations

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Contact

1325 W. Howard Street Evanston Illinois 60202

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