Neuro Packet Online Form Step 1 of 2 50% Name* First Last Guardian (If Applicable)Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneIn Depth Vision Optometry 3262 Fortune Court, Auburn, CA 95602 (530) 830-7007 What is a Neuro-optometric evaluation? This is a comprehensive evaluation done by an optometrist who is experienced in vision therapy and visual rehabilitation. Dr. Odineal is a board-certified vision therapy/rehab doctor. Why would I benefit from this? The eyes are an extension of the brain. When trauma, stroke, or oxygen deprivation occurs to the brain, it usually causes some form of visual dysfunction. The patient may be aware of double vision, eye strain, fatigue, blurred vision or other vision disturbances, or may be totally unaware of problems like visual field loss, visual field neglect, and poor eye teaming, tracking and focusing, and difficulties with dizziness and balance. These deficits can truly create problems with day to day function and can even create risk for the patient and others. What do I need to do to be seen for this type of evaluation? Dr. Odineal would like to know in advance about the patients she sees for neuro-evaluations. The testing is scheduled for a longer period of time than for general eye examinations and may be set for two separate visits to the office (depending on how fatigued or dizzy the patient is during the testing). It is very helpful, but not necessary, to have a written referral from a physiatrist, occupational therapist, physical therapist or speech pathologist along with a history of the problem and the appropriate diagnosis codes if you would like your insurance to cover these extended visits. Our office does not accept insurance, but the proper coding will be given to you for you to be able to bill your insurance if possible. The referring professional needs to fax referral and medical information to Dr. Odineal’s office, which she will review prior to your appointment (fax 530 718- 3270). It is helpful for Dr Odineal to review all the history before your visit to allow ample time for testing. If you are making an appointment at In Depth Vision for this testing, you will also need to have a comprehensive evaluation of your eyes done prior to the visit. In Depth Vision Optometry is a referral practice and we want to be assured that there are not eye health problems that need to be addressed. It is important for most neuro patients that have had traumatic brain injury or strokes to also have a threshold visual field test done as well. This test can be done at the time of the comprehensive eye examination, and also faxed to us prior to your visit. If you do not have an eye doctor to do this testing, please call our office for more information and a referral. What can I expect on the day of my appointment? You will need to be on time and prepared for a visit of approximately 40 minutes. Come in 20 minutes early to fill in our patient history form. If you are traveling far we will try and do as much testing as we can in one day. If you tire easily, get severe headaches, or are easily overwhelmed or confused, you may ask to break up the visit into two separate appointments. Dr. Odineal will do a thorough evaluation of eye muscle testing and teaming, balance, gait, and prescription. We will also evaluate the effect of various lenses, tints, and prisms in front of your eyes. Dr. Odineal may recommend prescription changes based on her findings, your difficulties, and your lifestyles and goals. Often recommendations are made for specific glasses and Dr. Odineal will want to reassess you after you have had time to adapt to the lenses. What is vision therapy and what can I expect if Dr. Odineal recommends this? Vision therapy is a prescribed series of eye/brain activities that rehabilitate visual problems such as double vision, eye teaming and tracking, perceptual problems, and difficulties resulting from visual field cuts or neglect. If you are working with an occupation/physical therapist Dr. Odineal will be communicating with them about your visual needs. Often the therapist can assist you in following simple visual activities prescribed by Dr. Odineal and her vision therapists. Frequently patients benefit from coming to the practice every week to work with us one on one, and to be taught home visual training techniques. Often, these therapy techniques are outside the scope of practice for an OT or PT and need to be supervised by a doctor who is trained in these procedures. This is especially true for patients with double vision. Dr. Odineal's vision therapy office (In Depth Vision Optometry, 3262 Fortune Ct., Auburn, CA (530) 830-7007) has specialized equipment that will also enhance functioning of patients with visual field loss. We will provide the tools you need to do these things (lenses, prisms, stereoscopes, workbooks, etc.). You will benefit by having a partner for vision therapy to do the home activities as well coming with you to the office sessions to learn how to do these exercises. Do not be discouraged. Change is forthcoming with perseverance. Celebrate the small changes that happen on your road to recovery. Our vision therapy office does not accept insurance but will provide you with a superbill to have your insurance reimburse you. Medicare does not cover vision therapy and vision rehabilitation services. Remember that just because an insurance coverage does not cover a procedure or treatment does not mean that this treatment is not of great value to the patient. We have seen tremendous positive changes in our patients that choose to invest in vision therapy! I have had a medical diagnosis of brain injury (check box if true) My brain injury wasyears ago I suffered a brain injury without medical diagnosis (check box if true) I have NOT had a previous brain injury (check box if true) Your AgePlease check the most appropriate box, or circle the item number that best matches your observations. All information will be held in confidence. Thank you for your help!SYMPTOM CHECKLIST Please rate each behavior. How often does each behavior occur? EYESIGHT CLARITYDistance vision blurred and not clear — even with lensesNeverSeldomOccasionallyFrequentlyAlwaysNear vision blurred and not clear — even with lensesNeverSeldomOccasionallyFrequentlyAlwaysClarity of vision changes or fluctuates during the dayNeverSeldomOccasionallyFrequentlyAlwaysPoor night vision / can’t see well to drive at nightNeverSeldomOccasionallyFrequentlyAlwaysVisual ComfortEye discomfort / sore eyes / eyestrainNeverSeldomOccasionallyFrequentlyAlwaysHeadaches or dizziness after using eyesNeverSeldomOccasionallyFrequentlyAlwaysEye fatigue / very tired after using eyes all dayNeverSeldomOccasionallyFrequentlyAlwaysFeel “pulling” around the eyesNeverSeldomOccasionallyFrequentlyAlwaysDoublingDouble vision — especially when tiredNeverSeldomOccasionallyFrequentlyAlwaysHave to close or cover one eye to see clearlyNeverSeldomOccasionallyFrequentlyAlwaysPrint moves in and out of focus when readingNeverSeldomOccasionallyFrequentlyAlwaysLIGHT SENSITIVITYNormal indoor lighting is uncomfortable — too much glareNeverSeldomOccasionallyFrequentlyAlwaysOutdoor light too bright - have to use sunglassesNeverSeldomOccasionallyFrequentlyAlwaysIndoors fluorescent lighting is bothersome or annoyingNeverSeldomOccasionallyFrequentlyAlwaysDRY EYESEyes feel “dry” and stingNeverSeldomOccasionallyFrequentlyAlways“Stare” into space without blinkingNeverSeldomOccasionallyFrequentlyAlwaysHave to rub the eyes a lotNeverSeldomOccasionallyFrequentlyAlwaysDEPTH PERCEPTIONClumsiness 1 misjudge where objects really areNeverSeldomOccasionallyFrequentlyAlwaysLack of confidence walking / missing steps / stumblingNeverSeldomOccasionallyFrequentlyAlwaysPoor handwriting (spacing, size, legibility)NeverSeldomOccasionallyFrequentlyAlwaysPERIPHERAL VISIONSide vision distorted / objects move or change positionNeverSeldomOccasionallyFrequentlyAlwaysWhat looks straight ahead—isn’t always straight aheadNeverSeldomOccasionallyFrequentlyAlwaysAvoid crowds / can’t tolerate “visually-busy” placesNeverSeldomOccasionallyFrequentlyAlwaysREADINGShort attention span / easily distracted when readingNeverSeldomOccasionallyFrequentlyAlwaysDifficulty / slowness with reading and writingNeverSeldomOccasionallyFrequentlyAlwaysPoor reading comprehension / can’t remember what was readNeverSeldomOccasionallyFrequentlyAlwaysConfusion of words / skip words during readingNeverSeldomOccasionallyFrequentlyAlwaysLose place / have to use finger not to lose place when readingNeverSeldomOccasionallyFrequentlyAlwaysSymptom Checklist (Continued)Do you have trouble with dizziness? Yes Do you bump into things on one side, or ignore one side? Yes Do you have trouble with balance? Yes Do letters appear to swim when reading? Yes Do you feel like the room spins when turning your head? Yes Tell me what is your most important visual goalPlease elaborate on any other visual problems Medical History Questionnaire OccupationBirth Date Date Format: MM slash DD slash YYYY Social SecurityLast Eye Exam Date Format: MM slash DD slash YYYY Name of Medical DoctorDr.’s PhoneEmail Last Medical Exam Date Format: MM slash DD slash YYYY Medical HistoryDo you have any allergies to medications? Yes Please explainList any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)List all major injuries, surgeries and/or hospitalizations you have hadList any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injuryAre you pregnant and/or nursing? Yes Do you wear glasses? Yes How old is your present pair of lenses?Do you wear contact lenses? Yes How old is your present pair of lenses?Type of contact lensesRigidSoftExtended WearAre they comfortable?YesNoFamily History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions. Skip if the answer is NO. DISEASE/CONDITIONBlindness Yes Unsure (?) RELATIONSHIP TO YOUCataract Yes Unsure (?) RELATIONSHIP TO YOUCrossed Eyes Yes Unsure (?) RELATIONSHIP TO YOUGlaucoma Yes Unsure (?) RELATIONSHIP TO YOUMacular Degeneration Yes Unsure (?) RELATIONSHIP TO YOURetinal Detachment/Disease Yes Unsure (?) RELATIONSHIP TO YOUArthritis Yes Unsure (?) RELATIONSHIP TO YOUCancer Yes Unsure (?) RELATIONSHIP TO YOUDiabetes Yes Unsure (?) RELATIONSHIP TO YOUHeart Disease Yes Unsure (?) RELATIONSHIP TO YOUHigh Blood Pressure Yes Unsure (?) RELATIONSHIP TO YOUKidney Disease Yes Unsure (?) RELATIONSHIP TO YOULupus Yes Unsure (?) RELATIONSHIP TO YOUThyroid Disease Yes Unsure (?) RELATIONSHIP TO YOUDo you have any other condition not listed? Yes Unsure (?) Please explainSocial History This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer Yes, I would prefer to discuss my Social History information directly with my doctor Do you drive? Yes Do you have visual difficulty when driving?YesNoPlease describeDo you use tobacco products? Yes Please share the type/amount/how longDo you drink alcohol? Yes Please share the type/amount/how longDo you illegal drugs? Yes Please share the type/amount/how longHave you ever been exposed to or infected with Gonorrhea Hepatitis HIV Syphilis Review of Systems Do you currently, or have you ever had any problems in the following areas SYSTEM CONSTITUTIONALFever, Weight Loss/Gain Yes Unsure (?) INTEGUMENTARY (Skin) Yes Unsure (?) NEUROLOGICALHeadaches Yes Unsure (?) Migraines Yes Unsure (?) Seizures Yes Unsure (?) EYESLoss of Vision Yes Unsure (?) Blurred Vision Yes Unsure (?) Distorted Vision/Halos Yes Unsure (?) Loss of Side Vision Yes Unsure (?) Double Vision Yes Unsure (?) Dryness Yes Unsure (?) Mucous Discharge Yes Unsure (?) Redness Yes Unsure (?) Sandy or Gritty Feeling Yes Unsure (?) Itching Yes Unsure (?) Burning Yes Unsure (?) Foreign Body Sensation Yes Unsure (?) Excess Tearing/Watering Yes Unsure (?) Glare/Light Sensitivity Yes Unsure (?) Eye Pain or Soreness Yes Unsure (?) Chronic Infection of Eye or Lid Yes Unsure (?) Sties or Chalazion Yes Unsure (?) Flashes/Floaters in Vision Yes Unsure (?) Tired Eyes Yes Unsure (?) ENDOCRINEThyroid/Other Glands Yes Unsure (?) EARS, NOSE, MOUTH, THROATAllergies/Hay Fever Yes Unsure (?) Sinus Congestion Yes Unsure (?) Runny Nose Yes Unsure (?) Post-Nasal Drip Yes Unsure (?) Chronic Cough Yes Unsure (?) Dry Throat/Mouth Yes Unsure (?) RESPIRATORYAsthma Yes Unsure (?) Chronic Bronchitis Yes Unsure (?) Emphysema Yes Unsure (?) VASCULAR / CARDIOVASCULARDiabetes Yes Unsure (?) Heart Pain Yes Unsure (?) High Blood Pressure Yes Unsure (?) Vascular Disease Yes Unsure (?) GASTROINTESTINALDiarrhea Yes Unsure (?) Constipation Yes Unsure (?) GENITOURINARYGenitals/ Kidney/Bladder Yes Unsure (?) BONES / JOINTS / MUSCLESRheumatoid Arthritis Yes Unsure (?) Muscle Pain Yes Unsure (?) Joint Pain Yes Unsure (?) LYMPHATIC / HEMATOLOGICAnemia Yes Unsure (?) Bleeding Problems Yes Unsure (?) ALLERGIC / IMMUNOLOGIC Yes Unsure (?) PSYCHIATRIC Yes Unsure (?) If you answered YES to any of the above or have a condition not listed, please explain & list medications.Doctor's Signature