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
Gender
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Occupation
Address
Street Address Address Line 2 City Province Postal Code
Alberta Health Care Number
Phone
Email
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)
MEDICAL HISTORY
Who is your primary care physician?
When was your last physical?
Please list any medical conditions (Diabetes, High Blood Pressure, Arthritis, etc.
Please list all current medication (prescription and over-the-counter)
Please list all drug allergies you have

QUALITY OF LIFE CHECKLIST

COVD Quality of Life Survey*

	Never	Seldom	Occasionally	Frequently	Always
Blurred close vision
Double vision
Headaches with near work
Words run together reading
Burning, itchy, watery eyes
Falls asleep reading
Sees worse at the end of day
Skips/repeats lines reading
Dizzy/nauseated by near work
Head tilt/one eye closed to read
Difficulty copying from board
Avoids near work/reading
Omits small words when reading
Writes uphill/downhill
Misaligns digits/columns of numbers
Poor reading comprehension
Poor/inconsistent in sports
Holds reading too close
Trouble keeping attention on reading
Difficulty completing work on time
Says "I can't" before trying
Avoids sports/games
Poor hand/eye coordination
Poor handwriting
Does not judge distance accurately
Clumsy, knocks things over
Poor time use/management
Does not make change well
Loses things/belongings
Car or motion sickness
Forgetfulness/poor memory

Check the column which best represents the occurrence of each symptom
Grand Total
Any other symptom/concerns not mentioned in the above checklist?

COMPUTER
Do you use computers in your work, school or leisure time activities?
- Yes
- No
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?
- Yes
- No
What distance is it?

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
if student. 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

MEDICAL HISTORY

QUALITY OF LIFE CHECKLIST

COMPUTER

HOBBIES/SPORTS

EMPLOYMENT OR SCHOOL