tnvisiontherapy.com - Sports Vision History Form

TENNESSEE VISION THERAPY

Please return all forms at least 48 hours prior to your appointment by fax, email or regular mail.
Patient’s Full Name*
Nickname*
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Name of School*
Grade*
HOW DID YOU HEAR ABOUT US?
Referred Name & Place of Business*
Internet Which terms did you search?*

Vision TherapyLazy EyeCrossed EyeADHDNone
Learning Disabilities*

ConvergenceAutismTracking IssuesReading IssuesNone
Current/Previous Patient*
CONTACT INFORMATION
Mother/Caretaker’s Name*
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Father/Caretaker’s Name*
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Sport #1 * # of hours playing sport(s) each day *
Team/Club Info*
Coach/Athletic Trainer(s)*
Sport #2 * # of hours playing sport(s) each day *
Team/Club Info*
Coach/Athletic Trainer(s)*
Sport #3 * # of hours playing sport(s) each day *
Team/Club Info*
Coach/Athletic Trainer(s)*
Your Child’s Medical History: Please fully complete
Pediatrician*
Date of Last Visit*

MonthDayYear
Date
Current Medications (include vitamins/supplements)*
Is your child allergic to any medications or medical preservatives?*

YesNo
Drug Allergies*
Have you had a sports injury in the last year?*

YesNo
If yes, please explain*
Have you had a concussion?*

YesNo
If yes, how many, when and how*
List illnesses, bad falls, high fevers, car accident, etc*
Your Medical History

Review of Systems *

Rows	List symptoms	Diagnosis	Surgeries	Hospitalization
Any new symptoms- fever, weight loss, night sweats, fatigue, etc.
Hematologic- anemia, excessive bleeding, etc.
Allergies/Immunologyswollen lymph noeds, anaphylaxis, etc.
Endocrine- diabetes, thyroid, hormonal, etc.
Psychiatric- depression, anxiety, etc.
Neurological- numbness, weakening, paralysis, etc.
Heart Problems- Chest pain, irregular heartbeat, high blood pressure, murmur, etc
Respiratory- short, shallow, or increased breathing, wheezing, etc
Ears/Nose/Throat- Sinus, hearing loss, etc
Gastrointestinal- Reflux, digestive or bowel issues, etc
Skin Disorders- rashes, dryness, cracking,etc.
Musculoskeletal- arthritis, joint pain, swelling, etc.
Genitourinary- pain, discomfort, red urine, etc

TENNESSEE VISION THERAPY

HOW DID YOU HEAR ABOUT US?

CONTACT INFORMATION

Your Child’s Medical History: Please fully complete

Your Medical History

YOUR VISUAL HISTORY

PRESENT SITUATION

SPORTS