Neuro Optometry Intake Survey

Neuro Optometry Intake Survey

Vantage Point Eyes - Dr. Holtman, Neuro-Optometrist
DISCLAIMER: Please keep in mind that communications over the internet are not secure. Although it is unlikely, there is a possibility that information you include in this form can be intercepted and read by other parties besides the person to whom it is intended. Please do not include personal identifying information such as your birth date, or personal medical information.

No one can diagnose your condition from email or other written communications, and communication via this form cannot replace the relationship you have with a healthcare practitioner.

None of the answers are required and, if preferred, can instead be addressed at the time of your visit; the intent of completing this ahead of time is to allow for more one on one time with the doctor at the time of your visit.
Name
Date Of Head Injury / Onset of Symptoms

MonthDayYear
Please briefly describe the nature of your injury.
Example: car accident where I was rear-ended, fell on black ice and hit back of head, etc
Current Symptoms (select all that apply)

Blurry vision far awayBlurry vision up closeVision appears to have a shadow to thingsDouble visionHeadachesDifficulty looking at screensLight sensitivity outdoorsLight sensitivity indoorsNauseaDizzy feelingFloatersEye strainVision lossOther
How many days in a typical week do you have some form of headache?
On average what is the severity of your headaches?
On a scale of 1-10, 10 being the worst.
Are you currently working?

No, not workingYes, same hours as prior to accidentYes, but hours are reduced
Are you currently driving? (Select all that are applicable)

No, not drivingYes, same as prior to accidentYes, but not on highwaysYes, but not at nightYes, but different than prior to accidentOther
Are you avoiding/not doing any activities that you did regularly prior to your accident?

ReadingShopping in storesGoing to entertainment events (concerts, sporting events etc)ExercisingWatching TVOther
Are you currently doing other therapies? (Select all that apply)

Not currently doing any therapyOT (Occupational Therapy)PT (Physical Therapy)MT (Massage Therapy)AcupunctureChiropractorCognitive TherapyPsychologySpeechOther
Are you doing eye related activities with any of the therapies listed above?

YesNoN/A
Prior to your recent incident, have you ever been in an accident? Describe briefly below.
Example: car accident 10 years ago, concussion playing hockey growing up
Did you play sports growing up or continue to now? Describe briefly below.
Example: growing up played hockey and lacrosse, currently play softball once per week
Prior to your recent indicent, have you ever been diagnosed as having a concussion?

YesNo
Number of known historical concussions:
Have you ever hit your head really hard but did not receive or seek medical care?

YesNo
Anything else that you would like the doctor to know prior to seeing you?
Thank you for completing this survey before your appointment with Dr. Holtman; we greatly appreciate the insight prior to your arrival. We look forward to meeting you at your appointment, please reach out if you have any questions in the meantime.

After hitting 'Submit' your answers will be sent to hello@vantagepointeyes.com.
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