NP TBI Eval Plano Step 1 of 6 16% PERSONAL INFORMATIONName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Gender* Male Female Birth Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone (Evening)*Business Phone (Day)Last Eye Exam* Last Medical Exam* Name of Parent, Spouse or Guardian* First Last Name of Medical Doctor* Doctor's Phone Number*Driver's License #* State* Social Security #* Occupation* E-mail Address* MEDICAL HISTORYList all major injuries, surgeries, and/or hospitalizations you have had List any medications you are currently taking (including aspirin / oral contraceptives / over the counter medications and home remedies) List all medications you are allergic to Are you pregnant or nursing? Yes Do you wear glasses? Yes how old is your present pair of glasses?* Do you wear contact lenses? Yes how old is your present pair of lenses?* Type of contact ?* Soft Extended Wear Rigid Gas Perm Other Are they comfortable?* Yes No Dry Blurry REVIEW OF SYSTEMSDo YOU currently, or have you ever had any problems in the following areasEYESPast Eye Injury YES Not Sure Loss of Vision YES Not Sure Blurred / Distorted Vision YES Not Sure Redness YES Not Sure Burning YES Not Sure Excess Tearing / Watering YES Not Sure Dryness YES Not Sure Halos / Glare YES Not Sure Eye Pain or Soreness YES Not Sure Sandy or Gritty Feeling YES Not Sure Foreign Body Sensation YES Not Sure Chronic Infection of lid / eye YES Not Sure Styes or Chalazion YES Not Sure Mucous Discharge YES Not Sure Flashes / Floaters YES Not Sure Double Vision YES Not Sure Tired Eyes YES Not Sure Macular Degeneration YES Not Sure Retinal Disease YES Not Sure Cataracts YES Not Sure Keratoconus YES Not Sure Corneal Transplant YES Not Sure Retinitis Pigmentosa YES Not Sure Strabismus (crossed / lazy eye) YES Not Sure CONSTITUTIONALFever, Weight loss / gain YES Not Sure INTEGUMENTARYSkin YES Not Sure Warts / Papilloma YES Not Sure NEUROLOGICALHeadaches YES Not Sure Migraines YES Not Sure Seizures YES Not Sure ENDOCRINEThyroid / Other Glands YES Not Sure Cancer YES Not Sure Type* EARS, NOSE, MOUTH, THROATAllergies / Hay Fever YES Not Sure Sinus Congestion YES Not Sure Runny Nose / Post- Nasal Drip YES Not Sure Chronic Cough YES Not Sure Dry Throat / Mouth YES Not Sure RESPIRATORYAsthma YES Not Sure Chronic Bronchitis YES Not Sure Emphysema YES Not Sure CARDIOVASCULAR / VASCULARDiabetes YES Not Sure High Cholesterol / Hyperlipidemia YES Not Sure High Blood Pressure YES Not Sure Heart / Vascular Disease YES Not Sure Heart / Chest Pain YES Not Sure GASTROINTESTINALDiarrhea YES Not Sure Constipation YES Not Sure GENITOURINARYGenitals / Kidney / Bladder YES Not Sure BONES / JOINTS / MUSCLES Rheumatoid Arthritis YES Not Sure Muscle Pain YES Not Sure Joint Pain YES Not Sure LYMPHATIC / HEMATOLOGICAnemia YES Not Sure Bleeding Problems YES Not Sure PSYCHIATRIC YES Not Sure OTHER If you answered YES to any of the above or have a condition not listed, please explain and list medications SOCIAL HISTORYThis information is kept strictly confidential, however you may discuss this directly with the doctor if you prefer. Yes, I would prefer to discus my Social History directly with the doctor Do you drive? Yes Do you have visual difficulty while driving? Yes Describe* Do you use tobacco products? YES Type / amount / how long?* Do you drink alcohol? YES Type / amount / how long?* Do you use illegal drugs? YES Type / amount / how long?* Have you ever been exposed or infected with Syphilis Gonorrhea Hepatitis HIV Other Please list the other condition(s):FAMILY HISTORYPlease note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: DISEASE / CONDITION Blindness YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSCataract YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSCrossed Eyes YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSGlaucoma YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSMacular Degeneration YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSRetinal Detachment YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSRetinal Disease YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSArthritis YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSDiabetes YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSHeart Disease YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSHigh Blood Pressure YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSHigh Cholesterol YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSKidney Disease YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSLupus YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSThyroid Disease YES Not Sure RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSOther HiddenName of Insurance Provider* HiddenPhone Number*HiddenEmployer* HiddenMember ID#* HiddenGroup #* Hidden* Primary Dependent HiddenIf Dependant, List Name and DOB of Primary* 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 Today's Date:* MM slash DD slash YYYY Provider Name:* Charles Shidlofsky, O.D., FCOVD Paul Kersjes O.D. Toni Schutte, O.D. Patient name:* First Last Insurance Company:* Member's Name:* Medical Insurance does not pay for the listed services below and therefore the patient is responsible for payment. Medical Insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. New Patient Neuro-Developmental Vision Eval / Traumatic Brain Injury Eval - $440 Previous Patient Neuro-Developmental Vision Eval / Traumatic Brain Injury Eval - $299 New Patient Autism Eval / Pediatric Eval - $229 Previous Patient Autism Eval / Pediatric Eval - $139 New Patient Binocular Vision Eval $299 Previous Patient Binocular Vision Eval $186 New Patient Wellness $189 Previous Patient Wellness $168 I want the testing/therapy listed above. I understand that my medical insurance will not be billed by our office for these procedures nor may I appeal to my insurance company. Signing below means that you have received and understand this notice:Signature* Patient/Parent or Guardians Name-if under 18year Date* MM slash DD slash YYYY *This ABN is valid for one year from date aboveFinancial Responsibility Policy for Charles Shidlofsky, O.D., P.A. d/b/a Neuro-Vision Associates of North Texas This document is provided to you so that you will understand both your responsibility as the patient, and our responsibility as the provider in regards to your insurance coverage. We accept assignment to many insurance companies, which means, we accept a negotiated rate as a provider. As a courtesy to our patients, we do file the initial insurance claims for those companies for which we have agreed to accept assignment. All insurance information must be presented at the time of your examination. We cannot accept any changes to this information past the date of service. After that time, we can provide any information you need so that you can file the claim on your own for reimbursement. Some health plans require that we inform you in advance that they may deny payment for “services not covered”, “services not deemed by the health plan to be reasonable and customary or medically necessary”, “services not covered for this type of provider”, “diagnosis not appropriate for this type of procedure”and “procedure has been deemed to be experimental”. Charles Shidlofsky, O.D., P.A. renders only services that, in their professional judgment, are necessary to provide quality health care for you. In order for us to collect from you for our services when payment is denied by your health plan, your health plan requires that you sign the following agreement. Agreement: I have been notified by Charles Shidlofsky, O.D., P.A. that payment may be denied for the reasons above, or that have been specifically requested by me, the patient. If payment is denied, I agree to be personally and fully responsible for payment within six months. Signature*Date* MM slash DD slash YYYY Your Health Plan Coverage Charles Shidlofsky O.D., P.A. is committed to providing you with the best possible care and helping you to receive maximum benefits under your health plan. In order to achieve these goals, we need your assistance. It is your responsibility to know if a referral is necessary for your visit Co-payments are due at the time of the visit. We are considered “Specialty Co-payments”. A valid, current insurance card must be presented at each office visit. If the service is not a covered benefit, or if your health plans tells us you are not covered, payment in full for all services rendered are due on date of service .If your insurance subsequently makes payment, any over payments will be refunded to you. Regarding Your Health Plan Your insurance is a contract between you, your employer and the insurance company. We are not party to that contract. While we may have an agreement with many of the health plans to provide services, any questions regarding coverage must be resolved by you with the insurance company. Not all services are a covered benefit in all contracts. Some health plans select certain services that they will not cover. By signing below, I acknowledge that I have read this information and understand completely. Signature*Date* MM slash DD slash YYYY Neuro-Vision Associates of North Texas and Affiliated Organizations Authorization of Use and Disclosure of Protected Health Information Expiration Date Of Authorization: There is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient. Right to Terminate or Revoke Authority: You may revoke this authorization by submitting a written revocation to Neuro-Vision Associates of North Texas and affiliated organizations. You should contact the Public Information Officer to terminate this authorization. Potential for Re-Disclosure: Information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation. Authorization to Contact and/or Leave Notice: Neuro-Vision Associates of North Texas and its affiliated organizations contacts patients by email or phone to remind or inform of future appointments or other medical information. This authorization allows us to contact you either by email or by leaving a message, for such purposes. Please list the contact phone number and names of persons with whom we may discuss your protected health information: Communication Preferences LocationHome Phone:*Can we contact you here?* Yes No Can we leave a text/message? Yes No Work Phone:Can we contact you here? Yes No Can we leave a text/message? Yes No Mobile Phone:Can we contact you here? Yes No Can we leave a text/message? Yes No Email address:* Can we contact you here?* Yes No Can we leave a text/message? Yes No Please list up to two people other than your insurance company or healthcare provider with whom we can talk to about your healthcare information: Name* First Last Relationship* Phone number*Email* Name* First Last Relationship* Phone number*Email* Signature : Signature of Patient*Name of Patient* First Last Date* MM slash DD slash YYYY HiddenSignature of Patient Representative*HiddenName of Patient Representative* First Last HiddenDate* MM slash DD slash YYYY ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that Neuro-Vision Associates of North Texas and its affiliated organizations make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: I have read or had explained to me that Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practice and agree to continue my care with that Neuro-Vision Associates of North Texas and its affiliated organizations under said terms. I was given to opportunity to read that Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practices and declined but wish to continue my care with that Neuro-Vision Associates of North Texas and its affiliated organizations under the tenns of that NeuroVision Associates of North Texas and its affiliated organizations privacy policies. I have read or had explained to me Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practice and do not wish to continue my care with Neuro-Vision Associates of North Texas and its affiliated organizations under said terms. The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as Please Type Patient Name* I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. Patient Signature*If you are signing as a personal representative of the patient, please indicate your relationship Notice of Privacy Practices Charles Shidlofsky, O.D. P.A. d/b/a Neuro-Vision Associates of North Texas And Affliated Companies: Neuro-developmental Eye Consultants, LLC d/b/a Neuro developmental Sensory Enhancement Center and VQ Optical, LP d/b/a Vision Quest Optical 7140 Preston Road Suites 200,300 and 400, Plano, TX 75024 972-312-0177 www.dr-s.net Charles Shidlofsky, O.D., FCOVD, Privacy Official IN COMPLIANCE WITH fflE FEDERAL REGULATIONS OF HIPAA'S PRIVACY RULE, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO IT We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not. Examples of how we might use or disclose health information for treatment purposes might include: Setting up or changing appointments including leaving messages with those at your home or office who may answer the phone or leaving messages on answering machines, voice mails, texts, or emails; calling your name out in a reception room environment; prescribing glasses, contact lenses, or medications as well as relaying this information to suppliers by phone, fax or other electronic means including initial prescriptions and requests from suppliers for refills; notifying you that your ophthalmic goods are ready, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voice mails, texts, or emails; referring you to another doctor for care not provided by this office; obtaining copies of health information from doctors you have seen before us; discussing your care with you directly or with family or friends you have inferred or agreed may listen to information about your health; sending you postcards or letters or leaving messages with those at your home who may answer the phone or on answering machines, voice mails, texts, or emails reminding you it is time for continued care; at your request, we can provide you with a copy of your medical records via email transmission or through our secure patient portal. Examples of how we might use or disclose health information for payment purposes might include: Asking you about your vision or medical insurance plans or other sources of payment; preparing and sending bills to your insurance provider or to you; providing any information required by third party payors in order to insure payment for services rendered to you; sending notices of payment due on your account to the person designated as responsible party or head of household on your account with fee explanations that could include procedures performed and for what diagnosis: collecting unpaid balances either ourselves or through a collection agency, attorney, or district attorney’s office. At the patient’s request, we may not disclose health care information for services you paid for out of pocket. This only applies to those encounters related to the care you want restricted. Examples of how we might use or disclose health information for business operations might include: Financial or billing audits; internal quality assurance programs; participation in managed care plans; defense of legal matters; business planning; certain research functions; informing you of products or services offered by our office; compliance with local, state, or federal government agencies request for information; oversight activities such as licensing of our doctors; Medicare or Medicaid audits; providing information regarding your vision status to the Department of Public Safety, a school nurse, or agency qualifying for disability status USES AND DISCLOSURES FOR OTHER REASONS NOT NEEDING PERMISSION In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations will never apply to you but they could. When a state or federal law mandates that certain health information be reported for a specific purpose For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices ! Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime ! Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative hearings ! Disclosures to a medical examiner to identify a deceased person or determine cause of death or to funeral directors to aid in burial ! Disclosures to organizations that handle organ or tissue donations ! Uses or disclosures for health related research ! Uses or disclosures to prevent a serious threat to health or safety of an individual or individuals ! Uses or disclosures to aid military purposes or lawful national intelligence activities ! Disclosures of de-identified information ! Disclosures related to a workman’s compensation claim ! Disclosures of a “limited data set” for research, public health, or health care operations ! Incidental disclosures that are an unavoidable by-product of permitted uses and disclosures ! Disclosure of information needed in completing form from a school related vision screening, information to the Department of Public Safety, information related to certification for occupational or recreational licenses such as pilots license. Disclosures to business associates who perform health care operations for of Neuro-Vision Associates of North Texas and its Affiliated company’s and who commit to respect the privacy of your information. We also require a business associate to require any subcontractor to comply with our privacy policies. ! Unless you object, disclosure of relevant information to family members or friends who are helping you with your care or by their allowed presence cause us to assume you approve their exposure to relevant information about your health USES OR DISCLOSURES TO PATIENT REPRESENTATIVES It is the policy of Neuro-Vision Associates of North Texas and its Affiliated company’s for our staff to take phone calls from individuals on a patients behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Neuro-Vision Associates of North Texas and its Affiliated company’s staff will also assist individuals on a patient’s behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient’s vision or health status may be disclosed without proper patient consent. of NeuroVision Associates of North Texas and its Affiliated company’s staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that individual. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written Authorization for Release of Identifying Health Information. The content of this authorization is determined by federal law. The request for signing an authorization may be initiated by NeuroVision Associates of North Texas and its Affiliated company’s or by you as the patient. We will comply with your request if it is applicable to the federal policies regarding authorizations. If we ask you to sign an authorization, you may decline to do so. If you do not sign the authorization, we may not use or disclose the information we intended to use. If you do elect to sign the authorization, you may revoke it at any time. Revocation requests must be made in writing to the Privacy Officer named at the beginning of this Notice. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your personal health information. You may ask us to restrict our uses and disclosures for purposes of treatment (except in emergency care), payment, or business operations. This request must be made in writing to Privacy Officer named at the beginning of this Notice. We do not have to agree to your request, but if we agree, must honor the restrictions you ask for. You may ask us to communicate with you in a confidential manner. Examples might be only contacting you by telephone at your home or using some special email address. We may accommodate these requests if they are reasonable and if you agree to pay any additional cost, if any, incurred in accommodating your request. Requests for special communication requests must be made to the Privacy Officer named at the beginning of this Notice. You may ask to review or get copies of your health information. There are a very few limited situations in which we may refuse your access to your health information. For the most part we are happy to provide you with the opportunity to either review or obtain a copy of your medical information. All requests for review or copy of medical information must be made in writing to the Privacy Officer named at the beginning of this Notice. While we usually respond to these requests in just a day or so, by law we have fifteen (15) days to respond to your request. We may request an additional thirty (30) day extension in certain situations. Health care information you request copies of may be delivered to you in electronic format. The eformats Neuro-Vision Associates of North Texas and its Affiliated company's has approved as secure and protects the integrity of your health care information include secure email, an authorized Electronic Health Information system and media supplied by Neuro-Vision Associates of North Texas and its Affiliated company's . You may ask us to amend or change your health care information if you think it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within thirty (30) days of your written request for change sent to the Privacy Officer named at the beginning of this Notice. We will then send the corrected information to you or any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include. You may ask us to amend or change your health care information if you think it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within thirty (30) days of your written request for change sent to the Privacy Officer named at the beginning of this Notice. We will then send the corrected information to you or any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include. You may request a list of any non-routine disclosures of your health information that we might have made within the past six (6) years (or a shorter period if you wish). Routine disclosures would include those used your treatment, payment, and business operations of of Neuro-Vision Associates of North Texas and its Affiliated company's. These routine disclosures will not be included in your list of disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $25.00 per list. We will usually respond to your written request (made to the Privacy Officer named at the beginning of this Notice) within thirty (30) days but we are allowed one thirty (30) day extension if we need the time to complete your request. You may obtain additional copies of this Notice of Privacy Practices from our business office or online at our website address shown at the beginning of this Notice. BREACH NOTIFICATION POLICY In the event of a reportable breach of patient information, Neuro-Vision Associates of North Texas and its Affiliated company's agrees to abide by the breach notification requirements as established by the HIPAA Breach Notification Rule. If a breach occurs, Neuro-Vision Associates of North Texas and its Affiliated company's will consult with a HIPAA attorney and take all necessary steps to remain in compliance with this rule including notification of individuals, Business Associates, the Secretary of Health and Human Services and prominent media outlets. WHISTLEBLOWER PROTECTION RULE Neuro-Vision Associates of North Texas and its Affiliated company's will take no action against any individual who provides information to the Office of Civil Rights, Office of the Inspector General or individual state Attorney General's Office regarding concerns related to the privacy and security procedures or actions at Neuro-Vision Associates of North Texas and its Affiliated company's. CHANGING OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to substantially change the Notice. We reserve the right to change this Notice at any time. If we change this Notice, the new privacy practices will apply to your existing health information as well as any additional information generated in the future. If we change this Notice, we will post a new Notice in our office and on our website. COMPLAINTS If you think that anyone at Neuro-Vision Associates of North Texas and its Affiliated company's has not respected the privacy of your health information, you are free to complain to the Privacy Officer named at the beginning of this Notice. We are more than happy to try to resolve any concern you may have in writing. lfwe cannot resolve your concern at that level, you may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights or the Texas Attorney General's Office. We will not retaliate against you if you make such a complaint. 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? Yes 2. Do you have dizziness or vertigo? Yes 3. Do you have double vision? Yes _At distance ?* _At near ?* 4. Do you lean or drift to the right? Yes _Left ?* _Forward ?* _Backward ?* _When ?* _Or sitting ?* 5. Do you have difficulty judging depth of stairs or curbs? Yes 6. Do you often feel disoriented ? Yes 7. Do you have an eye turn ? Yes _A head tilt ?* _Eye that squints ?* _Droopy eyelid ?* 8. Does print appear to “move” when you read? Yes 9. Do you lose your place when reading or tracking? Yes 10. Do you have blurry vision? Yes 11. Do you get headaches ? Yes _How often ?* _What part of the head does it affect ?* _Throbbing or dull ?* 12. Do your eyes hurt when you move them ? Yes 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 CHECKLISTCircle a number below· Please rate each behavior. How often does each behaviour occur? (circle a number)VISUAL COMFORTEye discomfort / sore eyes/ eyestrain Never Seldom Occasionally Frequently Always Headaches or dizziness after using eyes Never Seldom Occasionally Frequently Always Eye fatigue / very tired after using eyes all day Never Seldom Occasionally Frequently Always Feel "pulling" around the eyes Never Seldom Occasionally Frequently Always EYESIGHT CLARITYDistance vision blurred and not clear-- even with lenses Never Seldom Occasionally Frequently Always Near vision blurred and not clear-- even with lenses Never Seldom Occasionally Frequently Always Clarity of vision changes or fluctuates during the day Never Seldom Occasionally Frequently Always Poor night vision/ can't see well to drive at night Never Seldom Occasionally Frequently Always DOUBLINGDouble vision -- especially when tired Never Seldom Occasionally Frequently Always Have to close or cover one eye to see clearly Never Seldom Occasionally Frequently Always Print moves in and out of focus when reading Never Seldom Occasionally Frequently Always LIGHT SENSITIVITYNormal indoor lighting is uncomfortable- too much glare Never Seldom Occasionally Frequently Always Outdoor light too bright have to use sunglasses Never Seldom Occasionally Frequently Always Indoors fluorescent lighting is other some or annoying Never Seldom Occasionally Frequently Always DRY EYESEyes feel "dry" and sting Never Seldom Occasionally Frequently Always "Stare" into space without blinking Never Seldom Occasionally Frequently Always Have to rub the eyes a lot Never Seldom Occasionally Frequently Always DEPTH PERCEPTIONClumsiness / misjudge where objects really are Never Seldom Occasionally Frequently Always Lack of confidence walking missing steps / stumbling Never Seldom Occasionally Frequently Always Poor handwriting (spacing, size, egibility) Never Seldom Occasionally Frequently Always PERIPHERAL VISIONSide vision distorted / objects move or change position Never Seldom Occasionally Frequently Always What looks straight ahead--isn't always straight ahead Never Seldom Occasionally Frequently Always Avoid crowds/ can't tolerate "visually-busy" places Never Seldom Occasionally Frequently Always READINGShort attention span/ easily distracted when reading Never Seldom Occasionally Frequently Always Difficulty / slowness with reading and writing Never Seldom Occasionally Frequently Always Poor reading comprehension on/ can't remember what was read Never Seldom Occasionally Frequently Always Confusion of words/ skip words during reading Never Seldom Occasionally Frequently Always Lose place / have to use finger not to lose place when reading Never Seldom Occasionally Frequently Always Never Seldom Occasionally Frequently Always Signature*Date MM slash DD slash YYYY
