Name: Eye Health Centre
Address: 114-506 St. Albert Trail, St. Albert, AB, T8N 5Z1, CA
Telephone: 780-419-7000
Price range: $000 - $300

PATIENT INFORMATIONS
Patient Name
First Last
Who referred you to Eye Health Centre?
Date
MM slash DD slash YYYY

PRESENT SITUATION AND SYMPTOMS
What are the concerns that prompted this functional vision evaluation?
How long have these concerns been observed?
What goals do you hope to accomplish from the functional vision evaluation?

VISUAL HISTORY
Last Eye Exam (year)
Doctor
City
Were 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)

HOBBIES/SPORTS
Describe the activities that comprise the majority of your leisure time:
Do you watch TV?
- Yes
- No
How many hours per week?
Are you involved in athletics?
- Yes
- No
List the sports in which you participate
Are there any activities/sports you would like to participate in but don’t?
- Yes
- No
Please explain

EMPLOYMENT OR SCHOOL
Current Position
or Major 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
Describe briefly your daily activities at work or at school
Have you ever had a concussion
- Yes
- No
Please give details

Adult Questionnaire

Step 1 of 7 - PATIENT INFORMATIONS

PATIENT INFORMATIONS

PRESENT SITUATION AND SYMPTOMS

VISUAL HISTORY

QUALITY OF LIFE CHECKLIST

COMPUTER

HOBBIES/SPORTS

EMPLOYMENT OR SCHOOL