• The following information will help prepare your child for the upcoming appointment at our office. Your timely completion of these forms will allow us the needed time to process and review your case in advance. We ask that every page be filled out in its entirety and all pertinent medical records including the most recent eye exam are returned to our office at least two business days prior to the scheduled evaluation.

    What is a Developmental Vision Evaluation? 
    A Developmental Vision Evaluation includes checking the general health of the eye, visual acuity (20/20), refractive condition for appropriate corrective lenses when needed and all of the visual functions required for reading, writing, learning, sports performance and functioning in life. A developmental vision evaluation helps to pinpoint the precise area(s) of concern as well as the depth of the problem and to determine the best treatment options

    What tests are performed?
    Sensorimotor Testing- measures ocular motility, ocular alignment, and ocular deviation in more than one area of gaze and binocular fusion. It is necessary for detection, assessment, monitoring and guidance for the medical, surgical and optical management of binocular function and motor eye misalignment.

    Visual Perceptual Testing- tests the brain’s ability to make sense of what the eyes see. It is important for everyday activities such as dressing, eating, writing, and playing. When a child is behind in the development of visual processing skills, learning can take longer, requiring more cognitive effort that slows down the learning process.

    How long does the testing take?
    Testing takes approximately 2 hours and is scheduled in the morning before the eyes and brain are tired from a full day of school. We also like to do testing at this time so your child has eaten a good, high protein meal and is most attentive. We try our best to fully engage your child and to make it as fun as possible.

    Who can come to the appointment?
    Because full attention is needed, it is very important that you do not bring any additional family members such as siblings to the evaluation. We ask only the patient and parents. This minimizes distraction and enhances the productivity of the time spent in our office.

    What is my financial policy?
    Third parties, such as medical insurance, Medicare and TennCare, severely limit treatment, care options, and the time the Doctor and team can spend with you. Therefore, Tennessee Vision Therapy are a fee-for-service facility and payment is due in full at the time of service. The total cost of the Initial Visit is $350, which includes the evaluation, testing, consultation, and a follow-up summary of the Doctor’s findings.

    Will I get the results the same day?
    Yes! During your consultation all of the findings will be explained to you and literature will be provided. The recommendations from the Doctor, how to proceed and expectations will also be explained.

    We look forward to meeting you and your child!

  • Kindergarten-High School History Form

    Please return all forms at least 48 hours prior to your appointment by fax, email or regular mail.
  • Date of Birth*
     - -
  • Gender*

  • HOW DID YOU HEAR ABOUT US?

  • Internet: Which terms did you search?*
  • Learning Disabilities*

  • CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • YOUR CHILD’S MEDICAL HISTORY

    Please fully complete
  • Date of Last Visit*
     - -
  • Format: (000) 000-0000.
  • Is your child allergic to any medications?*
  • Did your child receive all of their recommended immunizations?*

  • Kindergarten-High School History Form

  • Rows
  • If your child has been professionally diagnosed with any of the following, please check*

  • YOUR CHILD’S VISUAL HISTORY

  • Has your child’s vision ever been evaluated?*
  • Does your child wear*
  • Has the patient ever had vision therapy?*
  • Is there any evidence from the school, psychological tests, or other tests that indicate somevisual issue may be present?*

  • YOUR CHILD’S DEVELOPMENTAL HISTORY

  • Is the patient adopted or foster child?*
  • Do you know prior medical history?*
  • Is the patient a multiple?*
  • Full-term pregnancy?*
  • Any pregnancy/delivery complications?*
  • Did your child crawl (on stomach)?*
  • Did your child creep (on all fours)?*
  • Was early speech clear to others?*
  • Is speech clear now?*

  • Your Child’s School and Reading Habits

  • Is your child homeschooled?*
  • Do you belong to a homeschooled group?*
  • Does your child attend public or private school?*
  • Did he/she graduate?*
  • Has your child changed schools often?*
  • Has a grade been repeated?*
  • Does your child like school?*
  • Does the patient currently have an Individualized Education Plan (IEP)?*
  • Does the patient currently have a 504 Plan or receive intervention at school?*
  • Has the patient had any special tutoring or remedial assistance?*

  • Which subjects are

  • Does your child like to read?*
  • Does your child read voluntarily?*
  • Is a lot of time/effort spent on maintaining this level of performance?*

  • How much time on average is spent each day on homework assignments? * hours

  • Do you and/or the teacher feel the patient is achieving up to potential?*

  • Kindergarten-High School History Form

  • Have any of the following evaluations been performed?

  • ABA evaluation?*
  • Currently in treatment?*
  • Format: (000) 000-0000.
  • Psychological evaluation?*
  • Currently in treatment?*
  • Format: (000) 000-0000.
  • Educational evaluation?*
  • Currently in treatment?*
  • Format: (000) 000-0000.
  • Occupational Therapy evaluation?*
  • Currently in treatment?*
  • Format: (000) 000-0000.
  • Speech Therapy evaluation?*
  • Currently in treatment?*
  • Format: (000) 000-0000.
  • Physical Therapy evaluation?*
  • Currently in treatment?*

  • Your Child’s Screen and Leisure Time Activities

  • Are there activities you/your child would like to participate in, but don’t?*

  • Kindergarten-High School History Form

  • Your Child’s Family and Home

  • Are there others living in your home?*
  • Does your child spend a significant amount of time with any other person not in the home?*
  • Has your child ever been through a traumatic family situation (separation, divorce, parental loss,separation from parents, severe parental illness, etc.)?*
  • Does your child seem to be adjusted?*
  • Was therapy/counseling undertaken?*
  • If yes, is it on-going?*
  • Format: (000) 000-0000.
  • Is family stable currently?*
  • Rows

  • SLEEP HABITS

  • Does your child sleep through the night?*
  • Does the patient use any sleep aids?*
  • Has the patient ever been diagnosed with and/or treated for sleep apnea?*
  • Does your child use CPAP/BiPAP?*
  • Has the patient ever experienced bedwetting?*
  • Is it ongoing?*

  • I hereby give my permission to Tennessee Vision Therapy to treat

  • Date*
     - -

  • Kindergarten-High School History Form

  • Release of information:

    It is often beneficial for us to discuss examination results and to exchange information with other professionals involved in your child’s care. Please sign below to authorize this exchange of information.

    I agree to permit information from, or copies of, my child’s examination records to be forwarded to myself or my child’s other health care providers upon their written request or upon recommendation of Tennessee Vision Therapy when it is necessary for the treatment of my child’s visual condition. I authorize Tennessee Vision Therapy, and their staff to exchange information with other professionals involved in my child’s care by means of my signature below. This authorization shall be considered valid throughout the duration of treatment.

  • Date*
     - -

  • Release of Information to Non-Medical Staff/Family Members

  • I * ,give permission for Tennessee Vision Therapy to release medical information to the following non-medical individual(s)- teachers, tutors, coaches.  

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date*
     - -

  • Kindergarten-High School History Form  

  • Patient Photo and Video Release Form

    I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my health information.

    This release is strictly designed to give permission to Tennessee Vision Therapy, to use my digital patient photos and/or video for their website, social media, and in office presentation for both educational and promotional purposes. Our providers and staff will have permission to use these photos in the manner discussed with me, unless I request the office no longer use them. I understand that by allowing Tennessee Vision Therapy to use my photos, I am expressing consent to share images publicly to educate and explain procedures and results of therapy. I understand that I have the option to decline this request and am not obligated in any way to
    provide permission to use these photos.

  • Please select the appropriate box*
  • Date*
     - -

  • Office Policy

    We schedule our appointments so that each patient receives the right amount of time to be seen
    by our physician and staff. That’s why it is very important that you keep your scheduled appointment with us and arrive on time with your new patient paperwork completed. As a courtesy, and to help patients remember their scheduled appointments, we send a confirmation email after scheduling and a reminder call a few days prior to your appointment. If your schedule
    changes and you cannot keep your appointment, please contact us so we may reschedule you,
    and accommodate those patients who are waiting for an appointment. As a courtesy to our office
    as well as to those patients who are waiting to schedule with the physician, please give us at
    least 24 hours’ notice.

  • COVD Lifestyle Checklist

  • Rows
  • Should be Empty: