Adult Case History
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please assign a value between 0 and 4 for each symptom.
0= never or non-existent / 1=seldom / 2=occasionally / 3=frequently / 4=always
General (If you don’t wear glasses, give yourself a score of 0 next to questions that ask about glasses)
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Rows
0
1
2
3
4
Things are blurry for a moment when you look up from reading or computer
work
You get headaches or eyestrain when you use your eyes for careful seeing.
Your stomach gets upset after you use your eyes.
Things blur in and out of focus.
It makes you nervous to search the crowded shelves in the grocery store.
Your glasses give you headaches or eyestrain even though you need them to see.
Your glasses make you sick to your stomach.
Since you started wearing glasses you find yourself avoiding reading.
Your glasses keep getting stronger
You would like to become less dependent on glasses
You have glasses, but avoid wearing them as often as possible
Your eye drifts in toward your nose or out toward your ear
For an eye that drifts, you have had surgery the following number of times.
At night, you have difficulty falling asleep.
Total Calculation
Driving
Rows
0
1
2
3
4
You get eyestrain or headaches when you drive
You get carsick, especially when sitting in the back seat.
You rapidly fatigue when driving.
You dislike driving at night.
You have difficulty judging how far away other cars are
You find parallel parking difficult
You have to look twice because you can't trust yourself to see things correctly the first time.
You have difficulty telling how fast other cars are moving.
You have trouble seeing road signs.
It makes you nervous to drive when traffic is heavy.
It makes you nervous to drive on the freeway
At night, the taillights ahead of you seem to double up.
You get lost easily when driving.
You worry about driving and limit your activities.
You have more trouble with computer and desk work as the day goes on
You have to schedule your computer and desk work in the morning when you're fresh
Your productivity goes down as the day progressesfresh
You get eyestrain or headaches during computer or desk work
Your stomach gets upset during computer or desk work.
You reverse numbers at work, such as seeing 36 for 63
You have to check your work for errors constantly because your eyes play tricks on you.
Your computer or desk work takes longer than it should.
You put off your desk work and instead spend your time talking, either face to on you.
You'd have second thoughts about a promotion if it meant more reading or desk
TOTAL CALCULATION
Reading
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Rows
0
1
2
3
4
When you read, the print blurs
When you read, the print runs together.
When you read, the print looks unsteady or dances
Reading gives you eye strain or headaches
Reading puts you to sleep.
You avoid reading for fun.
You avoid longer books.
You avoid books with smaller print
When you read, you get the feeling that you'd rather be somewhere else
You rapidly fatigue and lose comprehension when reading
You have to whisper to yourself when reading.
Reading gives you an upset stomach.
You lose your place and skip or reread lines.
You're afraid to read out loud in front of other people
Reading takes too much effort.
You read, "One . . . word . . . at . . . a . . . time."
You have to reread sentences to understand what you are reading.
TOTAL CALCULATION
Work
Rows
0
1
2
3
4
Service Quality
When you exercise, you prefer walking, running, swimming, calisthenics, or
lifting weights rather than visual activities such as baseball, tennis or golf.
When it comes to ball sports, you're a klutz.
You've always avoided participating in ball sports.
It's hard to catch or hit a ball.
When playing golf, your short game is more difficult.
When playing golf, it's not easy to read the green
When playing golf or tennis, you hit long or short
In whatever ball sport you play, it's harder to maintain your concentration the longer the game continues
In any ball sport, you're not as good as your technique would predict.
In tennis you have trouble with returning lobbed shots
In tennis, you have more difficulty at the net than at the baseline.
TOTAL CALCULATION
Coordination
Rows
0
1
2
3
4
It bothers you to walk downstairs
You bump into things.
When dancing, you have two left feet
It makes you nervous to walk in a crowd.
You feel clumsy.
You trip and stumble if you're not careful
TOTAL CALCULATION
Relationship
Rows
0
1
2
3
4
You have trouble maintaining eye contact when speaking to someone
You feel like backing further away when a person is speaking to you
You feel as if you need to move right up next to people when they are talking to you
You are too tired to enjoy your friends or family after a day of using your eyes
After a day of using your eyes, you are irritable or short-tempered
Sore eyes or headaches interfere with your relationships
Desk work drags on forever so you have little time left to enjoy your friends or family.
The effort it takes you to read has kept you from going back to school and is therefore limiting your income.
Your worries about driving limits the number of activities in which you or your children get to participate
Your reading ability affects your confidence.
Your driving ability affects your confidence
Your coordination affects your confidence
Having to wear glasses affects your confidence
You're embarrassed to be seen in glasses
You're embarrassed by the appearance of your eye turning.
When you speak with people they don't seem to know which of your eyes to look at.
When you speak with people they look over your shoulder to see where you are looking.
90 When you speak to people your attention is on holding your eyes straight
TOTAL CALCULATION
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
FINAL RESULT
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