Before Your Appointment Name(Required) Phone(Required)Email(Required) Upload FileMax. file size: 100 MB.NameThis field is for validation purposes and should be left unchanged. Patient Intake Form Name Coach D.O.B.: MM slash DD slash YYYY Relationship: HISTORYName of your eye condition (ocular diagnosis)? What is your chief complaint? Currently seeing an ophthalmologist? Yes No Name of your ophthalmologist: Last visit: When is your next visit? Who referred you to our agency? How long have you had this condition? Recent changes in your vision? Yes No QuestionsBetter seeing eye? Right Eye Left Eye Cataract surgery? Right Eye Left Eye Laser surgeries? Right eye Left eye Eye injections? Right eye Left eye Other eye surgeries? Right eye Left eye Eye drop name: Eye drop name: Right eye Left eye Do you take eye vitamins? Yes No Current health related concerns: Allergies Arthritis Anxiety Cholesterol Depression Heart Disease Osteoporosis Thyroid None Reaction Asthma Cancer Dementia Diabetes Hypertension Stroke Other Allergies Arthritis Anxiety Cholesterol Depression Heart Disease Osteoporosis Thyroid Reaction Asthma Cancer Dementia Diabetes Hypertension Stroke Other Provided meds. List Brain injury or Stroke (complete: Please explain when, rehab facility and affected areas) Do you have difficulty hearing? Yes No Do you use hearing aids? Yes No Do you use a mobility aid? Wheelchair Walker Cane None Do you smoke? Yes No Do you use a mobility aid? Wheelchair Walker Cane None How many packs a day? Do you use alcohol? yes No How often Height Weight B.P Sugar A1C Family history of vision impairment? Yes No If yes, describe Veteran? Yes No Branch of Service: Work status/history: Employed Part time Full time Retired Laid off Seeking a new job On Disability Work title or type: Where are you working? (company & location)? Does your employer know about your vision problems? YES No DON’T KNOW Do you have any vocational concerns at this time? Yes No Explain: FUNCTIONAL PROBLEMS DUE TO VISION LOSS MOBILITY CONCERNSDo you ever have difficulty getting around outside? Yes No Sometimes Seeing curbs or steps? Yes No Sometimes Bumping into things over head or on one side? Yes No Sometimes What side? Right Left Both Balance issues? Yes No Sometimes Do you go places by yourself? Yes No Sometimes DRIVING ISSUESDo you drive? Yes No Occasionally, but am not primary driver? Anytime Daytime only Locally Have you had any concerns while driving? Yes No Accidents or received tickets recently? Yes No Explain Explain Do you have a current license? Yes No When does your license expire? DISTANCE VISION:Do you have difficulty recognizing faces across a room? Yes No Are you able to see the TV? Yes No How big is your TV? How close do you sit? NEAR VISION: Can you read any of the following? Your mail Yes easily With difficulty Not at all Labels Yes easily With difficulty Not at all TV Remote Yes easily With difficulty Not at all Newspaper Yes easily With difficulty Not at all Write checks Yes easily With difficulty Not at all Glasses and Tools: Do you wear glasses? Yes No Sometime Distance only Reading only Bifocals PAL Trifocals How old is the pair you currently wear? Contact lens? Yes No Type Have you tried any magnifiers or other devices to help you see better? Yes No List List Are they helpful? Yes No Sometimes TECHNOLOGY USE QUESTIONSDo you, OR have you used a computer? Yes No Used to Do you currently have a computer? Yes No What do you use the computer for? E-mail Internet Social Media Games Banking Work Other What kind of computer do you have? PC Mac desktop laptop How old is your computer? Monitor size: What operating system does it have? Are you having difficulty:Seeing the screen? Yes No Sometimes Seeing the keyboard? Yes No Sometimes Are you using a tablet device? Yes No Type Are you having any difficulties using this device? Yes No Comments Do you use a cell phone? Yes No What Kind? Are you having problems using this phone? Yes No Comments LIGHTINGDo you use a lamp when reading? Yes No Sometimes What kind of lamp do you use? Do lights ever bother your eyes? Yes No Sometimes GLARE ISSUES Does glare bother you? Yes No Sometimes Outdoors: Yes No Indoors: Yes No Do you wear sunglasses? Yes No Sometimes Do you wear a hat or visor? Yes No Sometimes What activities occupy your daily routine? What activities are difficult or have you stopped doing because of your vision loss? GOALS FOR VISIT: How are you hoping we can help you? Be as specific as possible & rank them in order of importance. Distance / Mobility issues: Nearpoint issues: Computer issues: Glare issues: Employment concerns: Daily living problems / Other issues: Type of Living Arrangements Live Alone Live with Spouse Live with children Care giver Community Living Other Type of Residence Private home Condo or apartment Community Residential Town house Assisted Living Nursing Home Interviewer’s comments: SignatureDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. After Your Appointment Low Vision Device Instructions Hand-Held Magnifier Stand Magnifier (LED) Strong Reading Glasses Monocular Telescope General Infomation Amsler Grid Instructions Charles Bonnet Syndrome Electronic Video Magnification Desk-Top Video Magnifiers ClearView C + Speech: Optelec through NanoPac DaVinici Pro OCR: Enhanced Vision Onyx Desk-Jet HD: Freedom Scientific through NanoPac Topaz HD: Freedom Scientific through NanoPac Topaz OCR: Freedom Scientific through NanoPac Mattingly Mouse-Cam: Mattingly Low Vision Portable Video Magnifiers Mobilux Digital Touch HD 4.3": Eschenbach Optik Smartlux Digital 5" : Eschenbach Optik Explore 5": Humanware through NanoPac Ruby XL HD 5": Freedom Scientific through NanoPac Visolux Digital HD 7": Eschenbach Optik Compact 10" with OCR Option: Optelec through NanoPac Head- Mounted / Wearable Technology IrisVision Orcam: through NanoPac
