Visual ABI Questionnaire-Geelong

Visual ABI Questionnaire-Geelong
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Gender
Personal Pronouns
Do you wear glasses or contact lenses? Tick all that apply
When was your last eye exam?
Previously treated eye conditions other than with glasses? Eg. Eye surgery/Patching/Eye Exercises/Eye disease. If yes explain
Please list any family ocular conditions
Please list any medical issues prior to injury
Prior to injury did you suffer with? Tick all that apply:
Please list current medications
Please list current dietary supplements
Medical issues following injury
Regarding the injury:
Date of injury

MonthDayYear
Date
Loss of Consciousness
Associated Amnesia
How many hours or days did you have Amnesia
If you were diagnosed with concussion/whiplash: Time before concussion diagnosis? How many days?
Is this your first concussion?
If no please list other events
Do you have an associated neck/shoulder injury?
Did you have neck spinal problems prior to injury?
Please describe current sleep patterns
Are you experiencing headaches
What style of headache?
Where are the headaches located?
What is the frequency of the headaches?
Are there any triggers or associations?
Who referred you to this clinic? Word of mouth? Google? Referral?
Do you consent to us sending the report to other health care practitioners. Please list who you would like the report to be sent to:
Are you funded by:
Lifestyle:
Have you been able to return to work/learning?
Thinking about daily activities including shopping / cooking / cleaning/ personal hygiene / socialising / exercise
What percentage of daily activities would you estimate you can currently do compared to prior to injury? blanks %.
Do you have caring responsibilities? Tick all that apply
Are you able to drive? Tick all that apply
How far/long are you able to drive for?
What activities can you no longer engage in due to your visual difficulties?
Is there anything specific that you wish to achieve from this appointment?
Please note that by completing this form you consent to participating in a neuro visual examination. Your eye examination may include and is not limited to: Visual Acuity, possible spectacle prescription, a binocular vision assessment, use of equipment for scans and other assessments, and ocular health. These results will be documented in our medical records and in your report (if appropriate). The imaging from scans and glasses prescriptions are not included but may be requested. At Kiddies Eye Care our priority is your eye health. Please notify the Optometrist if you do not wish to participate in a specified test.

Additionally we are a private billing practice and payment is required at time of consultation. If you are funded by TAC or WorkSafe we will provide an invoice that will assist you to get reimbursed. Please call 5202 5911 for further clarification of fees.
Signature
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Visual ABI Questionnaire-Geelong

Regarding the injury:

Lifestyle:

Thinking about daily activities including shopping / cooking / cleaning/ personal hygiene / socialising / exercise