Neuro Packet Online Form

Name*

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Guardian (If Applicable)

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Work Phone

In 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 was

years 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 Age

Please 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 CLARITY

Distance vision blurred and not clear — even with lenses

Near vision blurred and not clear — even with lenses

Clarity of vision changes or fluctuates during the day

Poor night vision / can’t see well to drive at night

Visual Comfort

Eye discomfort / sore eyes / eyestrain

Headaches or dizziness after using eyes

Eye fatigue / very tired after using eyes all day

Feel “pulling” around the eyes

Doubling

Double vision — especially when tired

Have to close or cover one eye to see clearly

Print moves in and out of focus when reading

LIGHT SENSITIVITY

Normal indoor lighting is uncomfortable — too much glare

Outdoor light too bright - have to use sunglasses

Indoors fluorescent lighting is bothersome or annoying

DRY EYES

Eyes feel “dry” and sting

“Stare” into space without blinking

Have to rub the eyes a lot

DEPTH PERCEPTION

Clumsiness 1 misjudge where objects really are

Lack of confidence walking / missing steps / stumbling

Poor handwriting (spacing, size, legibility)

PERIPHERAL VISION

Side vision distorted / objects move or change position

What looks straight ahead—isn’t always straight ahead

Avoid crowds / can’t tolerate “visually-busy” places

READING

Short attention span / easily distracted when reading

Difficulty / slowness with reading and writing

Poor reading comprehension / can’t remember what was read

Confusion of words / skip words during reading

Lose place / have to use finger not to lose place when reading

Symptom 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 goal

Please elaborate on any other visual problems

Neuro Packet Online Form

Step 1 of 2

In Depth Vision Optometry
3262 Fortune Court, Auburn, CA 95602
(530) 830-7007

What is a Neuro-optometric evaluation?

SYMPTOM CHECKLIST

EYESIGHT CLARITY

Visual Comfort

Doubling

LIGHT SENSITIVITY

DRY EYES

DEPTH PERCEPTION

PERIPHERAL VISION

READING

Symptom Checklist (Continued)

Medical History Questionnaire

Medical History

Family History

Social History

Review of Systems

SYSTEM

CONSTITUTIONAL

INTEGUMENTARY (Skin)

NEUROLOGICAL

EYES

ENDOCRINE

EARS, NOSE, MOUTH, THROAT

RESPIRATORY

VASCULAR / CARDIOVASCULAR

GASTROINTESTINAL

GENITOURINARY

BONES / JOINTS / MUSCLES

LYMPHATIC / HEMATOLOGIC

ALLERGIC / IMMUNOLOGIC

PSYCHIATRIC

In Depth Vision Optometry

Step 1 of 2

In Depth Vision Optometry 3262 Fortune Court, Auburn, CA 95602 (530) 830-7007

What is a Neuro-optometric evaluation?

SYMPTOM CHECKLIST

EYESIGHT CLARITY

Visual Comfort

Doubling

LIGHT SENSITIVITY

DRY EYES

DEPTH PERCEPTION

PERIPHERAL VISION

READING

Symptom Checklist (Continued)

Medical History Questionnaire

Medical History

Family History

Social History

Review of Systems

SYSTEM

CONSTITUTIONAL

INTEGUMENTARY (Skin)

NEUROLOGICAL

EYES

ENDOCRINE

EARS, NOSE, MOUTH, THROAT

RESPIRATORY

VASCULAR / CARDIOVASCULAR

GASTROINTESTINAL

GENITOURINARY

BONES / JOINTS / MUSCLES

LYMPHATIC / HEMATOLOGIC

ALLERGIC / IMMUNOLOGIC

PSYCHIATRIC

In Depth Vision Optometry

In Depth Vision Optometry
3262 Fortune Court, Auburn, CA 95602
(530) 830-7007