Adult Questionnaire Please enable JavaScript in your browser to complete this form. - Step 1 of 8About You Name *FirstLastDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1CityState / Province / RegionPostal CodePhone *Email *Date / TimeDateTimeNextReason for ReferralWho suggested that you be seen by a behavioural optometrist?Why?What do you feel are your main difficulties and concerns?Have any other tests been carried out by Clinical Psychologist/Occupational Therapist/Neuro or Sports-physio Therapist/Neurologist?YesNoPlease give details of date of reports and send copies of report to read before appointmentIs there any further information on general health or issues you have concerns about?Please include any episodes of concussion or brain injury PreviousNextHistoryDo you have spectacles?YesNoIf yes please email me a copy of the prescription before your appointment.When was your last eye examination?DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you needed to see the hospital or orthoptist about your eyes?YesNoPlease give further details of hospital/orthoptist appointments and/or treatments:Is there any family history of a lazy eye?YesNoIs there any history of learning or reading problems in the close family?YesNoAre you right/left handed or ambidextrous?Right handedLeft handedAmbidextrousPreviousNextVisual Symptoms ChecklistPlease indicate below the frequency of your symptoms. If never, leave blank. Difficulty keeping your placeOccasionallyFrequentlySkipping or re-reading linesOccasionallyFrequentlyOmitting wordsOccasionallyFrequentlyWord by word readingOccasionallyFrequentlyDifficulty remembering what you have readOccasionallyFrequentlyExcessive head turningOccasionallyFrequentlyTilting headOccasionallyFrequentlyPoor sitting postureOccasionallyFrequentlyHolding head close to the pageOccasionally Frequently Closing or covering one eyeOccasionallyFrequentlyRubbing eyes during or after readingOccasionallyFrequentlyProblems with 3D movies or TV? - Fatigue/removing 3D spectacles/rubbing eyes/cannot watch them/cannot see the 3DOccasionallyFrequentlyShort attention spanOccasionallyFrequentlyAvoiding readingOccasionallyFrequentlyReversing words, letters and/or numbersOccasionallyFrequentlyLetters and/or words appear to fade, move, or shimmerOccasionallyFrequentlyWords seem to double or shadowOccasionallyFrequentlyPlease tick whichever of the following apply when doing close work:FrowningBlinkingSquintingOther facial expressionsPreviousNextBody posture and Space Awareness:Unusual AwkwardnessOccasionallyFrequentlyFrequent tripping and stumblingOccasionallyFrequentlyKnocking things off table/deskOccasionallyFrequentlyDifficulty with catching/throwingOccasionallyFrequentlyConfusing right and leftOccasionallyFrequentlyPreviousNextGeneral Behaviour:Avoiding close workOccasionallyFrequentlyDistractibleOccasionallyFrequentlyUnusual fatigue after close workOccasionallyFrequentlyTension during close work, including hunching over or wrigglingOccasionallyFrequentlyHeadaches during/after close workOccasionallyFrequentlyPreviousNextWriting and Other Desk Tasks:Difficulty copying from distance to nearOccasionallyFrequentlyOmitting words or phrasesOccasionallyFrequentlyRepeating words or phrasesOccasionallyFrequentlyConfusing the order of letters OccasionallyFrequentlyPoor handwritingOccasionallyFrequentlyDifficulty staying on the lineOccasionallyFrequentlyWriting neatly, but slowlyOccasionallyFrequentlyReversing letters or numbersOccasionallyFrequentlyGetting too close to the page OccasionallyFrequentlyTilting head to one sideOccasionallyFrequentlyPreviousNextAny further information you feel is useful:PreviousCommentSubmit
