Adult Questionnaire Please fill out the questionnaire carefully before 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. Step 1 of 7 - PATIENT INFORMATIONS 14% PATIENT INFORMATIONSPatient Name First Last Who referred you to Eye Health Centre?Date Date Format: MM slash DD slash YYYY 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 the 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) QUALITY OF LIFE CHECKLISTCheck the column which best represents the occurrence of each symptomBlurred close visionNeverSeldomOccasionallyFrequentlyAlwaysDouble visionNeverSeldomOccasionallyFrequentlyAlwaysHeadaches with near workNeverSeldomOccasionallyFrequentlyAlwaysWords run together readingNeverSeldomOccasionallyFrequentlyAlwaysBurning, itchy, watery eyesNeverSeldomOccasionallyFrequentlyAlwaysFalls asleep readingNeverSeldomOccasionallyFrequentlyAlwaysSees worse at the end of dayNeverSeldomOccasionallyFrequentlyAlwaysSkips/repeats lines readingNeverSeldomOccasionallyFrequentlyAlwaysDizzy/nauseated by near workNeverSeldomOccasionallyFrequentlyAlwaysHead tilt/one eye closed to readNeverSeldomOccasionallyFrequentlyAlwaysDifficulty copying from chalkboardNeverSeldomOccasionallyFrequentlyAlwaysAvoids near work/readingNeverSeldomOccasionallyFrequentlyAlwaysOmits small words when readingNeverSeldomOccasionallyFrequentlyAlwaysWrites uphill/downhillNeverSeldomOccasionallyFrequentlyAlwaysMisaligns digits/columns of numbersNeverSeldomOccasionallyFrequentlyAlwaysPoor reading comprehensionNeverSeldomOccasionallyFrequentlyAlwaysPoor/inconsistent in sportsNeverSeldomOccasionallyFrequentlyAlwaysHolds reading too closeNeverSeldomOccasionallyFrequentlyAlwaysTrouble keeping attention on readingNeverSeldomOccasionallyFrequentlyAlwaysDifficulty completing work on timeNeverSeldomOccasionallyFrequentlyAlwaysSays "I can't" before tryingNeverSeldomOccasionallyFrequentlyAlwaysAvoids sports/gamesNeverSeldomOccasionallyFrequentlyAlwaysPoor hand/eye coordinationNeverSeldomOccasionallyFrequentlyAlwaysPoor handwritingNeverSeldomOccasionallyFrequentlyAlwaysDoes not judge distance accuratelyNeverSeldomOccasionallyFrequentlyAlwaysClumsy, knocks things overNeverSeldomOccasionallyFrequentlyAlwaysPoor time use/managementNeverSeldomOccasionallyFrequentlyAlwaysDoes not make change wellNeverSeldomOccasionallyFrequentlyAlwaysLoses things/belongingsNeverSeldomOccasionallyFrequentlyAlwaysCar or motion sicknessNeverSeldomOccasionallyFrequentlyAlwaysForgetfulness/poor memoryNeverSeldomOccasionallyFrequentlyAlwaysGrand TotalAny other symptom/concerns not mentioned in the above checklist? COMPUTERDo you use computers in your work, school or leisure time activities?YesNoPlease indicate the types of computer work you perform Select All Word processing Programming Data Entry Internet Games Others How many hours do you spend in front of a computer screen in a day?How do your eyes feel after working at the computer?Do you use multiple screens?Is your computer screen about arms length away from you?YesNoWhat distance is it? HOBBIES/SPORTSDescribe the activities that comprise the majority of your leisure time:Do you watch TV?YesNoHow many hours per week?Are you involved in athletics?YesNoList the sports in which you participateAre there any activities/sports you would like to participate in but don’t?YesNoPlease explain EMPLOYMENT OR SCHOOLCurrent Positionor Major course of studyHow 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?YesNoDo you feel you are getting adequate return from the amount of effort you put into a task?YesNoDescribe briefly your daily activities at work or at schoolHave you ever had a concussionYesNoPlease give details
