Neuro Packet Name* First Last DOB: MM slash DD slash YYYY Phone*Email* Were You Referred By Another Professional? Yes No Referral Name First Last Referral PhoneReferral Email Referral Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country In Depth Vision Optometry 3262 Fortune Court, Auburn, CA 95602 (530) 830-7007 What is a Neuro-optometric evaluation? This is a comprehensive evaluation done by an optometrist who is experienced in vision therapy and visual rehabilitation. Dr. Odineal is a board-certified vision therapy/rehab doctor. Why would I benefit from this? The eyes are an extension of the brain. When trauma, stroke, or oxygen deprivation occurs to the brain, it usually causes some form of visual dysfunction. The patient may be aware of double vision, eye strain, fatigue, blurred vision or other vision disturbances, or may be totally unaware of problems like visual field loss, visual field neglect, and poor eye teaming, tracking and focusing, and difficulties with dizziness and balance. These deficits can truly create problems with day to day function and can even create risk for the patient and others. What do I need to do to be seen for this type of evaluation? Dr. Odineal would like to know in advance about the patients she sees for neuro-evaluations. The testing is scheduled for a longer period of time than for general eye examinations and may be set for two separate visits to the office (depending on how fatigued or dizzy the patient is during the testing). It is very helpful, but not necessary, to have a written referral from a physiatrist, occupational therapist, physical therapist or speech pathologist along with a history of the problem and the appropriate diagnosis codes if you would like your insurance to cover these extended visits. Our office does not accept insurance, but the proper coding will be given to you for you to be able to bill your insurance if possible. The referring professional needs to fax referral and medical information to Dr. Odineal’s office, which she will review prior to your appointment (fax 530 718- 3270). It is helpful for Dr Odineal to review all the history before your visit to allow ample time for testing. If you are making an appointment at In Depth Vision for this testing, you will also need to have a comprehensive evaluation of your eyes done prior to the visit. In Depth Vision Optometry is a referral practice and we want to be assured that there are not eye health problems that need to be addressed. It is important for most neuro patients that have had traumatic brain injury or strokes to also have a threshold visual field test done as well. This test can be done at the time of the comprehensive eye examination, and also faxed to us prior to your visit. If you do not have an eye doctor to do this testing, please call our office for more information and a referral. What can I expect on the day of my appointment? You will need to be on time and prepared for a visit of approximately 40 minutes. Come in 20 minutes early to fill in our patient history form. If you are traveling far we will try and do as much testing as we can in one day. If you tire easily, get severe headaches, or are easily overwhelmed or confused, you may ask to break up the visit into two separate appointments. Dr. Odineal will do a thorough evaluation of eye muscle testing and teaming, balance, gait, and prescription. We will also evaluate the effect of various lenses, tints, and prisms in front of your eyes. Dr. Odineal may recommend prescription changes based on her findings, your difficulties, and your lifestyles and goals. Often recommendations are made for specific glasses and Dr. Odineal will want to reassess you after you have had time to adapt to the lenses. What is vision therapy and what can I expect if Dr. Odineal recommends this? Vision therapy is a prescribed series of eye/brain activities that rehabilitate visual problems such as double vision, eye teaming and tracking, perceptual problems, and difficulties resulting from visual field cuts or neglect. If you are working with an occupation/physical therapist Dr. Odineal will be communicating with them about your visual needs. Often the therapist can assist you in following simple visual activities prescribed by Dr. Odineal and her vision therapists. Frequently patients benefit from coming to the practice every week to work with us one on one, and to be taught home visual training techniques. Often, these therapy techniques are outside the scope of practice for an OT or PT and need to be supervised by a doctor who is trained in these procedures. This is especially true for patients with double vision. Dr. Odineal's vision therapy office (In Depth Vision Optometry, 3262 Fortune Ct., Auburn, CA (530) 830-7007) has specialized equipment that will also enhance functioning of patients with visual field loss. We will provide the tools you need to do these things (lenses, prisms, stereoscopes, workbooks, etc.). You will benefit by having a partner for vision therapy to do the home activities as well coming with you to the office sessions to learn how to do these exercises. Do not be discouraged. Change is forthcoming with perseverance. Celebrate the small changes that happen on your road to recovery. Our vision therapy office does not accept insurance but will provide you with a superbill to have your insurance reimburse you. Medicare does not cover vision therapy and vision rehabilitation services. Remember that just because an insurance coverage does not cover a procedure or treatment does not mean that this treatment is not of great value to the patient. We have seen tremendous positive changes in our patients that choose to invest in vision therapy! I have had a medical diagnosis of brain injury (check box if true) Date of Brain InjuryDescribe Your Brain InjuryThis field is hidden when viewing the formMy brain injury wasyears ago I suffered a brain injury without medical diagnosis (check box if true) I have NOT had a previous brain injury (check box if true) Your AgeThis field is hidden when viewing the formToday's Date MM slash DD slash YYYY Your Zip CodePlease 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 Please rate each behavior. How often does each behavior occur? 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 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 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 bothersome 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 1 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, legibility) 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 / 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 Symptom Checklist (Continued)1. Do you experience double vision?* Yes No Is this at all times?* Yes No Is this at distance or near?2. Do you have trouble with dizziness?* Yes No 3. Do you have problems with loss of place when reading?* Yes No 4. Do you bump into things on one side, or ignore one side?* Yes No 7. Do you have trouble with balance?* Yes No 8. Do letters appear to swim when reading?* Yes No 9. Do you feel like the room spins when turning your head?* Yes No 12. Tell me what is your most important visual goal13. Please elaborate on any other visual problemsMedical History Questionnaire Name* First Last This field is hidden when viewing the formToday’s Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Work PhoneGuardian (If Applicable)OccupationBirth Date MM slash DD slash YYYY Last Eye Exam MM slash DD slash YYYY Name of Medical DoctorDr.’s PhoneEmail Last Medical Exam MM slash DD slash YYYY Medical HistoryDo you have any allergies to medications? Yes No If yes, explainList any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)List all major injuries, surgeries and/or hospitalizations you have hadList any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injuryAre you pregnant and/or nursing? Yes No Do you wear glasses? Yes No If yes, how old is your present pair of lenses?Do you wear contact lenses? Yes No If yes, how old is your present pair of lenses?Type of contact lenses Rigid Soft Extended Wear Other Are they comfortable? Yes No Family History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions DISEASE/CONDITIONCataract* YES NO ? Crossed Eyes* YES NO ? Glaucoma* YES NO ? Macular Degeneration* YES NO ? Retinal Detachment/Disease* YES NO ? Arthritis* YES NO ? Cancer* YES NO ? Diabetes* YES NO ? Heart Disease* YES NO ? High Blood Pressure* YES NO ? Kidney Disease* YES NO ? Lupus* YES NO ? Thyroid Disease* YES NO ? OtherSocial History This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer Yes, I would prefer to discuss my Social History information directly with my doctor Do you drive? Yes No If yes, do you have visual difficulty when driving? Yes No If yes, please describeDo you use tobacco products? Yes No If yes, type/amount/how longDo you drink alcohol? Yes No If yes, type/amount/how longDo you use illegal drugs? Yes No If yes, type/amount/how longHave you ever been exposed to or infected with Gonorrhea Hepatitis HIV Syphilis Review of Systems Do you currently, or have you ever had any problems in the following areas SYSTEM CONSTITUTIONALFever, Weight Loss/Gain* Yes No ? INTEGUMENTARY (Skin)* Yes No ? NEUROLOGICALHeadaches* Yes No ? Migraines* Yes No ? Seizures* Yes No ? EYESLoss of Vision* Yes No ? Blurred Vision* Yes No ? Distorted Vision/Halos* Yes No ? Loss of Side Vision* Yes No ? Double Vision* Yes No ? Dryness* Yes No ? Mucous Discharge* Yes No ? Redness* Yes No ? Sandy or Gritty Feeling* Yes No ? Itching* Yes No ? Burning* Yes No ? Foreign Body Sensation* Yes No ? Excess Tearing/Watering* Yes No ? Glare/Light Sensitivity* Yes No ? Eye Pain or Soreness* Yes No ? Chronic Infection of Eye or Lid* Yes No ? Sties or Chalazion* Yes No ? Flashes/Floaters in Vision* Yes No ? Tired Eyes* Yes No ? ENDOCRINEThyroid/Other Glands* Yes No ? EARS, NOSE, MOUTH, THROATAllergies/Hay Fever* Yes No ? Sinus Congestion* Yes No ? Runny Nose* Yes No ? Post-Nasal Drip* Yes No ? Chronic Cough* Yes No ? Dry Throat/Mouth* Yes No ? RESPIRATORYAsthma* Yes No ? Chronic Bronchitis* Yes No ? Emphysema* Yes No ? VASCULAR / CARDIOVASCULARDiabetes* Yes No ? Heart Pain* Yes No ? High Blood Pressure* Yes No ? Vascular Disease* Yes No ? GASTROINTESTINALDiarrhea* Yes No ? Constipation* Yes No ? GENITOURINARYGenitals/ Kidney/Bladder* Yes No ? BONES / JOINTS / MUSCLESRheumatoid Arthritis* Yes No ? Muscle Pain* Yes No ? Joint Pain* Yes No ? LYMPHATIC / HEMATOLOGICAnemia* Yes No ? Bleeding Problems* Yes No ? ALLERGIC / IMMUNOLOGIC* Yes No ? PSYCHIATRIC* Yes No ? This field is hidden when viewing the formIf you answered YES to any of the above or have a condition not listed, please explain & list medications.This field is hidden when viewing the formDate MM slash DD slash YYYY CAPTCHA Δ
