Adult's Vision Questionnaire

Full Name

First NameLast Name

Date of Birth

Contact phone number:

Address

Street Address

CityState

Postal Code

Email Address

example@example.com.au

Medicare card number:

Medicare card patient reference number:

Medicare card expiry:

Current general practitioner (GP) name and clinic:

Occupation

What is the main reason for your visit?

Do you suffer from any of the following?

Please provide further information:

Do you take any medications?

YesNo

Please list any medications:

Do you suffer from any allergies in general and/or to any medications or eye drops?

YesNoNot Sure

Please list any allergies:

Is there a family history of (please select all options that apply):

Please provide further relevant information below:

Have you had a previous eye examination?

YesNo

If yes, when was your last eye examination?

Do you wear spectacles or contact lenses?

YesNo

If yes, please select the corresponding reasons for the spectacles/contact lenses below:

Please provide further relevant information below:

Have you suffered from a recent or previous injury (concussion, stroke, brain injury, trauma to the head/neck, etc.)?

YesNo

Date of the injury:

DD/MM/YY

Prior to the injury, did you suffer from any of the following:

Please select all options that are relevant to your injury:

Please provide further relevant information regarding the injury below:

Have you been able to return to work/learning?

YesNo

What activities can you no longer engage-in due to your visual difficulties?

How would you describe your sleep patterns?

Good qualityAdequatePoor QualityConstant Challenge

Do you suffer from headaches?

YesNo

If yes, please select any option that relates to your headaches:

Dull (tension)Throbbing (pulsing)Sharp (ice pick)Other

Please provide further relevant information regarding the headaches below (location, frequency):

Do you suffer from any of the following symptoms?

Rows	Never	Sometimes	Often	Always	N/A
Difficulty changing focus or sustaining focus
Bothered by noise
Motion sickness/car sickness
Difficulty recalling
Difficulty with time management
Glare
Sensitivity to light
Flashes
Floaters

Do you suffer from any of the following symptoms?

Rows	Never	Sometimes	Often	Always	N/A
Blurry vision
Double vision
Eye strain/Tired eyes
Eye rubbing
Covering or closing one eye at times
Red eyes
Itchy eyes
Watery eyes
Dry eyes
Glare
Sensitivity to light
Floaters
Flashes
Losing track when reading
Poor concentration
Words look blurry when reading
Blurry distance vision
Words moving on the page

Brain Injury Vision Symptom Survey: How often do you experience any of the following?

Rows	0 Never	1 Seldom	2 Occasionally	3 Frequently	4 Always
Distance Vision blurred and not clear - even with lenses
Near vision blurred and not clear - even with lenses
Clarity of vision changes or fluctuates during the day
Poor night vision/ Can't see well to drive at night
Eye discomfort, sore eyes/ eye strain
Headaches or dizziness after using eyes
Eye fatigue/ very tired after using eyes all day
Feel "pulling" around the eyes
Double vision - especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading
Normal indoor lighting is uncomfortable - too much glare
Outdoor light too bright - have to use sunglasses
Indoor fluorescent lighting bothersome or annoying
Eyes feel "dry" and sting
"Stare" into space without blinking
Have to rub eyes a lot
Clumsiness/ misjudge where objects really are
Lack of confidence walking/ missing steps/ stumbling
Poor handwriting (spacing, size, legibility)
Side vision distorted (objects move or change position)
What looks straight ahead - isn't always straight ahead
Avoid crowds/ can't tolerate "visually busy" places
Short attention span/ easily distracted when reading
Difficulty/ slowness with reading and writing
Poor reading comprehension/ can't remember what was read
Confusion of words/ skip words during reading
Loses place/ have to use finger not to lose place when reading

How often do you experience any of the following?

Rows	Never	Sometimes	Often	Always	N/A
Difficulty changing focus or sustaining focus
Bothered by noise
Motion sickness/ car sickness
Awkward/ poor balance
Difficulty recalling information
Difficulty with time management
Stare into space without blinking
Clumsiness/ misjudge where objects really are
Lack of confidence walking/missing steps/ stumbling
Poor handwriting
Side vision distorted/ objects move or change position
What looks straight isn't always straight
Avoid crowds/ can't tolerate "visually busy" places
Short attention span/ easily distracted when reading
Difficulty/slowness when reading and writing
Poor reading comprehension/ can't remember what was read

Please provide further information on the reason for your visit, should it not be already outlined in the previous table:

Would you like a report from your eye examination to be forwarded to someone in particular?

YesNo

Please list below the details and contact information for all individuals you would like reports from your eye examination to be sent to:

E.g: GP, Physiotherapist, Endocrinologist, etc.

Should there be any further documents or referrals you would like the Optometrist to view, please forward all information to our email address: info@bassendeanoptical.com.au

How did you hear about us?

Other: