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.
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 EyeADHD
Learning Disabilities

ConvergenceAutismTracking IssuesReading Issues
Current/Previous Patient
CONTACT INFORMATION
Mother/Caretaker’s Name
Cell
Please enter a valid phone number.
Email
example@example.com
Work Phone
Please enter a valid phone number.
Father/Caretaker’s Name
Cell
Please enter a valid phone number.
Email
example@example.com
Work Phone
Please enter a valid phone number.
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

	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