Adult HX Forms Packet Survey

Full Name
Preferred Name
Marital Status
Home Phone
Cell Phone
Other Phone
Which phone you Preferred
Emergency Contact
Phone Number
Primary insurance
Secondary Insurance
Family Eye Doctor
Last Eye Exam
Referred By: (Check all that apply)

Medical Information

Primary Care Provider Name:
Date of Last Exam
Have you received any of the following examinations? Check any that appy and write down in the name of the provider.
Born Premature or Complications at Delivery
Formal Diagnosis of
Estimated reading ability?
How many hours a day are you on the computer?
Hours Reading or Studying?

Strabismus/Amblyopia (Wandering/Crossed or Lazy Eyes)

Direction of wandering eye?
At what age did you or others first notice the eye wander?
Have reduced vision in one eye even after corrected with glasses?
Have you done patching?
Kind of patching?
At what age was your child first diagnosed with Amblyopia (reduced vision in one eye with glasses)?
At what age did your child start wearing glasses?
Do you get headaches when reading, doing computer work, or other visual tasks?
Where are they located?
More one side of the head than another?
Patient’s Name:
How frequently?
How long do they last?
How severe on a 1 to 10 scale (10=severe)?
Do you take anything or do anything to relieve the headaches?
Do your relief strategies work?

Head Injury/Stroke/Other Neurological Insult? (Use the back of the final page if you need more space to describe)

Please describe including date of injury and accompanying signs and symptoms:
Have you had head imaging?
Are you under the care of a physician for the above event?
Were any of the signs or symptoms mentioned above present before this event?
Is there any other information you feel would be helpful/important in your treatment?
Patient’s Name:

Review of Systems​​​​​​​

Please mark each box. Indicate Yes or No for any current diagnoses or symptoms for the following.

General Constitutional (Unexplained fever, weight loss or gain, etc.)
Eyes: (Disease related such as Glaucoma, Detached Retina)
Ears, Nose, Throat, Mouth: (Hearing loss, chronic nasal congestion, chronic cough)
Respiratory: (Asthma, chronic bronchitis, shortness of breath, etc.)
Cardiovascular (Diabetes, hypertension, heart problems, etc.)
Gastrointestinal (diarrea, constipación, hernia, ulcers, etc.)
Genitourinary (Painful urination, frequent urination, jaundice, etc.)
Hematological/Lymphatic (Anemia, bleeding problems, etc.)
Musculoskeletal (Muscle Pain, trauma, osteoarthritis, osteoporosis, etc.)
Skin (Eczema, Psoriasis, rases etc.)
Neurological (Epilepsy, Cerebral Palsy, tumor, etc.)
Psychiatric (ADHD, Depression, anxiety, etc.)
Endocrine (Diabetes, Thyroid problem, etc.)

Personal Medical History

Please List all current medications:
Does the patient have any of the following illnesses or conditions (Please check and describe in the list below):
Does the patient have any of the following eye conditions (Please check and describe in the list below)?
Do you suffer from or have endured:

Family Medical History

Check each one Yes or No to indicate of any member of your family has had these diseases. Family history includes your parents, grandparents, siblings, and your children.
Macular Degeneration
Retinal Detachment
Strabismus (eye turn or crossed eyes)
Amblyopia (Lazy Eye)
Dyslexia (or other reading problems)
High Blood Pressure
Heart Disease
Thyroid Disease

Social History

Please answer the following questions (for young children you can select N/A):
Do you currently or have you in the past used tobacco products?
Please describe your alcohol consumption (how many days per week you drink and how many drinks you have in an average week)?(for young children you can write N/A):
If you use them, please describe your use of Recreational/Street drugs (How long you have taken them, what type, the amount taken, and the frequency of taking them)?
Female: Are you pregnant?

Visual Signs/Symptoms Checklist


Visual Perception

Visual Discrimination
Visual Figure-Ground
Visual-Motor Processing Issues
Form Constancy Issues
Visual Closure
Visual-Spatial Issues
Long or Short-Term Visual Memory Issues
Visual Sequencing Issues
Long Lasting (Chronic) Condition
Recent (Acute) Condition
Excess Condition
Emotional Fatigue
Reactive Condition
Emotional/Post-traumatic Condition

Release of Information


I'm the Parent of and undersigned give Eye Therapy, permission to release any Protected Health Care Information regarding my medical records, including diagnosis to other health care professionals, specifically, but not limited to those listed below, when it is necessary for the treatment of my visual condition.

Primary Care Physician/Clinic
Primary Eye Doctor/Clinic
Other Physician/Clinic
Spouse/Significant Other


Name of the signer below
Name of the Child
Parent’s or Guardian’s Signature (Initial)
Expires on:


Eye Therapy is willing to provide you with an ESTIMATE of what your insurance will or will not cover. However, we cannot and do not guarantee that the ESTIMATE we provide is correct. When we as the provider or you call in to get the ESTIMATE it is given with the statement “this is not a guarantee of payment”. Please understand that while we will assist you in understanding your benefits, we have no influence over your coverage. You are ultimately responsible for all fees and charges on your account.

I understand that payment in full is due at time of service unless other arrangements have been made.

authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I also give permission for Eye Therapy to release any Medical Records requested by my insurance company for claim processing. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.

Thank you,

I have read and accept this policy,

Patient name
Responsible party name
Signature of Parent/Guardian (Initial)


Our office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend your privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our vision and medical care operations. Your personal health information will never be otherwise given to anyone, even family members, without your written consent. You, of course, may give written authorization for us to disclose your information to anyone that you choose, for any purpose.

Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information
We will only request personal information needed to provide our standard of quality vision and medical care, implement payment activities, conduct normal optometric practice operations, and comply with the law. This may include your name, address, telephone number(s), social security number, employment data, medical history, and health records. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law

Disclosure of Protected Health InformationAs stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and government officials under certain circumstances. We will not use your information for third party marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments, including voice mail messages, answering machines, postcards, and email.

Patient Rights
You have the right to request copies of your healthcare information and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

HIPAA Privacy Practice Acknowledgment

I have received or was offered and declined a notice of privacy practices.

Patient name
Signature of Parent/Guardian (Initial)


On a scale from 0-10 (10 being most severe) how severe are the following symptoms while doing visual tasks?

1 Headaches (In general including frequency and severity)
Score :
Comments :
2 Eye strain, soreness, pain, or discomfort
Score :
Comments :
3 Eyes get tired and generally become tired
Score :
Comments :
4 Double vision, shadowing of letters, words move, jump, swim, appear to float on the page
Score :
Comments :
5 Blurry Vision even though glasses are on or have been told glasses are unnecessary
Score :
Comments :
6 Loss of place, skipping words and/or lines while reading, or have to reread the same line of words
Score :
Comments :
7 Motor Coordination/Difficulties with Depth perception (accident prone, poor hand-eye coordination, avoid or have poor performance in sports, frequently knock things over, trip, fall, or run into things, poor rhythm/timing)
Score :
Comments :
8 Academic Concerns (Poor Interest in reading and school, poor reading comprehension, poor grades, homework takes longer than it should, poor handwriting)
Score :
Comments :
9 Visual Perceptual Difficulties (Letter reversals, confusion with words, letters, numbers, symbols, get lost in details, fatigues or becomes confused with too much info on page, confused with different fonts, poor visual recall)
Score :
Comments :
10 Balance/Dizziness/Vertigo/Disorientation/Nausea?
Score :
Comments :
11 Poor attention, focus, concentration, hyperactivity?
Score :
Comments :
12 Brain fog, sensory overstimulation, motor overload (Unable to think clearly with too much stimulus, overwhelmed with too much light, sound, busy visual environments/patterns, unable to sit still or reflexive movements due to overstimulation)
Score :
Comments :
13 Behavior problems, poor self-esteem/confidence, easily frustrated, anxiety, depression
Score :
Comments :
14 Eye wanders or crosses?
Score :
Comments :
15 Other - please describe: (difficulty with multitasking, auditory processing difficulties, etc.
Score :
Comments :