Adult Vision Therapy Intake Form Name First Last Home PhoneCell PhoneEmail Address Address Street Address 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 Alberta Health Care #Family DoctorDOB MM slash DD slash YYYY Contact Preference E-mail Text Phone Do you have: Dry eyes Cataracts Glaucoma Macular degeneration Family Ocular History Glaucoma Macular degeneration Wandering eye Have you had eye surgery? LASIK Cataracts Other OtherDate of surgery MM slash DD slash YYYY Do you wear contact lenses? Yes No Family Medical History High blood pressure Diabetes Heart disease Cancer Other check all that applyOtherPersonal Medical History High blood pressure Diabetes Heart disease Thyroid dysfunction Arthritis Lupus Sarcoidosis MS Migraines Asthma COPD Sleep apnea Cancer Other (check all that applyOtherMedication(s) Add Removeincluding eye dropsHerbals/Vitamins Add RemoveAllergies Add RemoveWho referred you to Eye Health Centre?Patient History QuestionnairePlease fill out questionnaire carefully and return it to the office at the time of your appointment. The time spent answering questions will allow the doctor to better plan the flow of the examination procedures. Thank you for your time and effort in completing this questionnaire. Leave blank or put N/A besides questions that do not apply.PRESENT SITUATION AND SYMPTOMSWhat are the concerns that prompted this functional vision evaluation?How long have these concerns been observed?What goals do you hope to accomplish from this functional vision evaluation?VISUAL HISTORYLast Eye Exam (year)DoctorCityWere glasses, contact lenses or other optical devices prescribed or recommended? If so, what? and do you use them? If not using them, why?Explain any history of eye surgeries, eye/head injury, vision therapy or other treatments in the past (related or not to current concerns:COMPUTERDo you use computers in your work, school or leisure time activities?If so, indicate the types of computer work you perform: Word processing Programming Data Entry Internet Games Others OthersHow many hours do you spend in front of a computer screen in a day?How do your eyes feel after working at the computer?How do your eyes feel after working at the computer?Is your computer screen about arm’s length away from you? Yes No If not, what distance is it?HOBBIES/SPORTSDescribe the activities that comprise the majority of your leisure timeDo you watch TV? Yes No How many hours per week?Are you involved in athletics? Yes No List the sports in which you participate: Add RemoveAre there any activities/sports you would like to participate in but don’t? If so, please explainEMPLOYMENT OR SCHOOLCurrent PositionMajor course of study:How many hours per day do you spend sitting at a desk?How many hours per day do you spend reading of studying?How many hours per day do you spend working at near distances?Do you feel you are achieving your potential at work or school? Yes No Do you feel you are getting adequate return from the amount of effort you put into a task? Yes No Have you ever had a concussion? Yes No Please give details Δ
