NP TBI Eval Plano

Name: Neuro-Vision Associates of North Texas
Address: 7140 Preston Rd, Ste 300, Plano, TX, 75024, US
Telephone: 972-312-0177
Price range: $000 - $300

Step 1 of 6

Neuro-Vision Associates
of North Texas Charles
Shidlofsky, O.D., P.A.
Plano/Southlake/Rockwall
972-312-0177
www.neurovisionassociates.com
TBI Questionnaire

Name*
First Last
Date of Exam*
MM slash DD slash YYYY

Referring Dr.*

Facility*

OT*

PT*

SLP*

Insurance Co. or Workers Comp*

Date of Injury*
MM slash DD slash YYYY

Type of Injury*

Pertinent medical history*

How has your vision changed since your TBI?*
1. Are you aware or your left side/right side?*

2. Do you have dizziness or vertigo?*

3. Do you have double vision?*

_At distance ?*

_At near ?*

4. Do you lean or drift to the right?*

_left ?*

_forward ?*

_Backward ?*

_when ?*

_or sitting ?*

5. Do you have difficulty judging depth of stairs or curbs?*

6. Do you often feel disoriented ?*

7. Do you have an eye turn ?*

_a head tilt ?*

_Eye that squints ?*

_Droopy eyelid ?*

8. Does print appear to “move” when you read?*

9. Do you lose your place when reading or tracking?*

10. Do you have blurry vision?*

11. Do you get headaches ?*

_How often ?*

_What part of the head does it affect ?*

_Throbbing or dull ?*

12. Do your eyes hurt when you move them ?*

Please use the space below to write any questions or comments that you have:
My brain injury was*
#years ago
My age is*
years
today's date*
MM slash DD slash YYYY

I have had a medical diagnosis of brain iniu.o: (check box if true) Cause of injury:*

I sustained a brain injury without medical diagnosis (check box if true)*

I have NOT ever sustained a brain injury (check box if true)*

Please check the most appropriate box, or circle the item number that best matches your observations. All information will be held in confidence. Thank you for your help!

SYMPTOM CHECKLIST Circle a number below·
Please rate each behavior.

How often does each behaviour occur? (circle a number)
EYESIGHT CLARITY*
Never Seldom Occasionally Frequently Always
Distance vision blurred and not clear-- even with lenses
Near vision blurred and not clear-- even with lenses
Clarity of vision changes or fluctuates during the day
Poor night vision/ can't see well to drive at night
VISUAL COMFORT*
Never Seldom Occasionally Frequently Always
Eye discomfort / sore eyes/ eyestrain
Headaches or dizziness after using eyes
Eye fatigue / very tired after using eyes all day
Feel "pulling" around the eyes
DOUBLING*
Never Seldom Occasionally Frequently Always
Double vision -- especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading
LIGHT SENSITIVITY*
Never Seldom Occasionally Frequently Always
Normal indoor lighting is uncomfortable- too much glare
Outdoor light too bright have to use sunglasses
Indoors fluorescent lighting is other some or annoying
DRY EYES*
Never Seldom Occasionally Frequently Always
Eyes feel "dry" and sting
"Stare" into space without blinking
Have to rub the eyes a lot
DEPTH PERCEPTION*
Never Seldom Occasionally Frequently Always
Clumsiness / misjudge where objects really are
Lack of confidence walking missing steps / stumbling
Poor handwriting (spacing, size, egibility)
PERIPHERAL VISION*
Never Seldom Occasionally Frequently Always
Side vision distorted / objects move or change position
What looks straight ahead--isn't always straight ahead
Avoid crowds/ can't tolerate "visually-busy" places
READING*
Never Seldom Occasionally Frequently Always
Short attention span/ easily distracted when reading
Difficulty / slowness with reading and writing
Poor reading comprehension on/ can't remember what was read
Confusion of words/ skip words during reading
Lose place / have to use finger not to lose place when reading
Signature*
Date*
MM slash DD slash YYYY

NP TBI Eval Plano

Step 1 of 6

PERSONAL INFORMATION

MEDICAL HISTORY

REVIEW OF SYSTEMS

EYES

CONSTITUTIONAL

INTEGUMENTARY

NEUROLOGICAL

ENDOCRINE

SOCIAL HISTORY

FAMILY HISTORY

DISEASE / CONDITION

Neuro-Vision Associates of North Texas
and
Neuro-Developmental Sensory Enhancement
Center 7140 Preston Rd. Ste. 300
Plano, TX. 75024
Phone: (972)312-0177
www.dr-s.net
Advanced Beneficiary Notice

Financial Responsibility Policy for
Charles Shidlofsky, O.D., P.A.
d/b/a Neuro-Vision Associates of North Texas

Your Health Plan Coverage

Regarding Your Health Plan

Neuro-Vision Associates of North Texas and Affiliated Organizations
Authorization of Use and Disclosure of Protected Health Information

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Notice of Privacy Practices

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

USES AND DISCLOSURES FOR OTHER REASONS NOT NEEDING PERMISSION

USES OR DISCLOSURES TO PATIENT REPRESENTATIVES

OTHER USES AND DISCLOSURES

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

BREACH NOTIFICATION POLICY

WHISTLEBLOWER PROTECTION RULE

CHANGING OUR NOTICE OF PRIVACY PRACTICES

COMPLAINTS

Neuro-Vision Associates
of North Texas Charles
Shidlofsky, O.D., P.A.
Plano/Southlake/Rockwall
972-312-0177

TBI Questionnaire

Step 1 of 6

PERSONAL INFORMATION

MEDICAL HISTORY

REVIEW OF SYSTEMS

EYES

CONSTITUTIONAL

INTEGUMENTARY

NEUROLOGICAL

ENDOCRINE

SOCIAL HISTORY

FAMILY HISTORY

DISEASE / CONDITION

Neuro-Vision Associates of North Texas and Neuro-Developmental Sensory Enhancement Center 7140 Preston Rd. Ste. 300 Plano, TX. 75024 Phone: (972)312-0177 www.dr-s.net Advanced Beneficiary Notice

Financial Responsibility Policy for Charles Shidlofsky, O.D., P.A. d/b/a Neuro-Vision Associates of North Texas

Your Health Plan Coverage

Regarding Your Health Plan

Neuro-Vision Associates of North Texas and Affiliated Organizations Authorization of Use and Disclosure of Protected Health Information

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Notice of Privacy Practices

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

USES AND DISCLOSURES FOR OTHER REASONS NOT NEEDING PERMISSION

USES OR DISCLOSURES TO PATIENT REPRESENTATIVES

OTHER USES AND DISCLOSURES

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

BREACH NOTIFICATION POLICY

WHISTLEBLOWER PROTECTION RULE

CHANGING OUR NOTICE OF PRIVACY PRACTICES

COMPLAINTS

Neuro-Vision Associates of North Texas Charles Shidlofsky, O.D., P.A. Plano/Southlake/Rockwall 972-312-0177

TBI Questionnaire

Neuro-Vision Associates of North Texas
and
Neuro-Developmental Sensory Enhancement
Center 7140 Preston Rd. Ste. 300
Plano, TX. 75024
Phone: (972)312-0177
www.dr-s.net
Advanced Beneficiary Notice

Financial Responsibility Policy for
Charles Shidlofsky, O.D., P.A.
d/b/a Neuro-Vision Associates of North Texas

Neuro-Vision Associates of North Texas and Affiliated Organizations
Authorization of Use and Disclosure of Protected Health Information

Neuro-Vision Associates
of North Texas Charles
Shidlofsky, O.D., P.A.
Plano/Southlake/Rockwall
972-312-0177