Visual ABI Questionnaire-Geelong

Visual ABI Questionnaire-Geelong
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Personal Pronouns
Do you wear glasses or contact lenses?
What do you wear glasses or contact lenses for?
When was your last eye exam?
Previously treated eye conditions (other than glasses)? Eg. Eye surgery, patching, eye exercises, eye disease. If yes, please elaborate:
Please list any family ocular conditions:
Please list any medical issues prior to injury:
Prior to injury did you suffer with:
Please list current medications:
Please list current dietary supplements:
Medical issues following injury:
Regarding the injury:
Date of injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Loss of Consciousness?
Associated Amnesia?
If yes, how many hours / days did you have amnesia?
If you were diagnosed with concussion/whiplash: Time between injury and concussion diagnosis (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?
Lifestyle:
What is your occupation?
Have you been able to return to work/study?
With regards to activities of daily living (eg. 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?
Are you able to drive?
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?
How did you find this service at our clinic?
Do you consent to us sending the report to other health care practitioners involved in your care? Please list who you would like the report to be sent to:
Are you funded by:
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: