Adult Vision Questionnaire GENERAL INFORMATION:Full Name: First Last Male Female Birth Date MM slash DD slash YYYY Age:Home Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone:Cell Phone:Marital Status: Single Married Divorced Widowed Were you referred to our office? Yes No whom may we thank for this referral?PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Occupation:Employer:Business Address:Spouse’s Name:Occupation:Spouse’s EmployerBusiness Address:Please list your spouse and dependents:Spouse:Birth Date: MM slash DD slash YYYY Dependent:Birth Date: MM slash DD slash YYYY Dependent:Birth Date: MM slash DD slash YYYY Dependent:Birth Date: MM slash DD slash YYYY MEDICAL HISTORY:Date of most recent evaluation: MM slash DD slash YYYY Physician’s Name: First Last For what problem or condition?Results and recommendations:Medications currently using including vitamins and supplements:For what condition?Are you allergic to any foods or medications? Yes No please list:Current diet: Excellent Good Fair Poor Current state of health (explain):Is there any history of the following? (Please check)Diabetes Patient Family WhoMultiple Sclerosis Patient Family WhoBlindness Patient Family WhoGlaucoma Patient Family WhoHigh Blood Pressure Patient Family WhoStrabismus/crossed eye Patient Family WhoAmblyopia/lazy eye Patient Family WhoThyroid Condition Patient Family WhoCataracts Patient Family WhoBrain Tumor Patient Family WhoVISUAL HISTORY:Have you had a previous vision examination? Yes No Doctor’s name: First Last Date of last visit: MM slash DD slash YYYY Reason for examination:Results and recommendations:Were glasses, contact lenses, or other optical devices prescribed or recommended? Yes No What?Do you use them? Yes No When?How long have you had them?Why not?If you wear contact lenses, how long have you worn them?That type of lenses do you have (i.e. hard, soft, gas-permeable)?What solutions do you use?Members of the family who have had visual diagnoses and the reason:Name Add RemoveAge Add RemoveVisual Situation Add RemovePRESENT SITUATION:Why do you feel the need for a visual evaluation?How long has this problem/difficulty existed?Please check if you have the following: Blurred vision at distance Blurred vision at near Red or itchy eyes Burning eyes Frequent Sties Watery eyes Eyes hurt Eyes feel tires Headaches Nausea associated with visual tasks Halos around lights Double vision at distance Double vision at near Tilt head during desk work Squinting, covering or closing one eye Postural changes with desk work Need for very bright light when reading Need for very dim light when reading Loss of interest or short attention span for close work Difficulty sustaining reading/writing General or visual fatigue at end of day Loss of place often when reading Skip lines when reading Repetition of letter or words when reading Omission of words when reading/copying Use of finger to keep place Head moves when reading Confusion of what is being seen or read Falling asleep when reading Silent vocalization/moving lips while reading Motion/car sickness Difficulty with reading comprehension Comprehension decreases over time Letters or words appear to move or float around when reading Difficulty aligning columns of numbers Can respond better orally than in writing Write or print poorly Poor time management Inconsistent performance in work or sports Poor general coordination/clumsiness Poor fine motor coordination Difficulties with short-term memory Difficulties with long-term memory Comments on any items above:COMPUTERS:Do you use a computer in your work, school, or leisure time activities? Yes No Indicate the types of computer work you perform: Word processing Programming Data Entry Internet Games/Leisure activities Other ExplainHow many hours do you spend in front of a computer screen each day?How do your eyes feel after working at the computer?Where is the top of the screen located? Above your straight-ahead eye level At eye level Below eye level What is the distance from: Your eyes to the screen?Your eyes to the keyboard?Your eyes to your source documents?Where is the computer screen located? Directly in front of you when seated To your right To your left Where are your source documents located? Directly in front of you when seated To your right To your left Flat (horizontal) or vertical Do you experience any of the following lighting problems in your work area? Glare from windows or other light sources Reflections on your computer screen Difficulty reading source documents Do you wear glasses, contact lenses, or other optical devices for computer work? Glasses Contact lenses Other ExplainCOMPUTERS (continued):Please describe any problems you have with your vision, current glasses or contact lenses for computer work:EMPLOYMENT OR SCHOOL:Current position:Major course of study:How many hours daily do you spend at a desk?How many hours daily do you spend reading or studying?How many hours daily do you spend working at near distances?Do you feel you are achieving to your potential in work or school? Yes No Do you feel you are getting adequate return for the amount of effort you put into a task? Yes No Please explain:Does your work or course of study demand comprehension from the written word? Yes No Describe briefly your daily activities at work or in school:HOBBIES/SPORTS:Describe the types of activities that comprise the majority of your leisure time:Do you watch TV? Yes No How many hours per day?How many days per week?Are you seriously involved with athletics? Yes No Do you feel you are achieving up to your potential in sports/athletics? Yes No Of all the sports you have played: List the ones in which you excel:List the ones in which you do poorly/avoid: Δ
