Adult Questionnaire

Address

Are you presently experiencing any of the following? (check all that apply)

______	Blurred vision
______	Headaches
______	Difficulty in depth perception
______	Burning of the eyes
______	Itchy eyes
______	Difficulty with driving
______	Tearing/watery eyes
______	Light sensitivity
______	Poor sports performance
______	Redness of the eyes
______	Double vision
______	Tired/sleepy doing visual tasks
______	Short attention span
______	Slow reading
______	Loss of place while reading
______	Back or neck pain
______	Low reading comprehension
______	Eye(s) turn in/out/up/down
______	Computer visual discomfort
______	Clumsiness/bumping into things

Other
Are there any special demands you have at work or at home?
Are there any hobbies or recreational activities with special visual demands?
Vision History
Date of your last vision or eye exam:
Eye Doctor's name:
Eye Doctor's address:
Diagnoses and recommendations:
Were glasses prescribed?
If so, do you wear them now?
What do you wear the glasses for?
Have you ever been involved in vision therapy? When?
Doctor's name and address:
Have you ever had an eye patched? If so, when?
Detail any history of eye disease or surgery:
Do you ever see bright flashes of light or floating spots?
Have you ever had an injury to your eye or eyes? If so, please explain:
Have you ever suffered a head or brain injury? If so, please explain:
Contact Lenses History
Do you wear contact lenses?
Soft or RGP?
If not, are you interested?
When did you start wearing contact lenses?
Type and brand of contact lenses?
How many hours per day:
How many hours per week:
Medical History
Check all that apply:

High blood pressure Diabetes Arthritis Cancer Allergies/Asthma Heart disease Glaucoma Cataracts
Other:
List any medications you are currently using:
Do you have any allergies?
Name of your physician:
Address:
May we send a report of our findings to your physician?

Yes No

Is there any family history of:

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Vision History