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11200 Highland Rd, Hartland, MI 48353 –

810-632-5240

TBI (Traumatic Brain Injury) History Form

Fields marked with an asterisk are required.

Name:

Date of Birth:

Age now:

Date:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

SSN:

Referred by:

Current medications:

Allergies:

Date of accident/trauma:

Describe the accident/trauma:

Type of Accident

Motor Vehicle

Type of vehicle you were in:

If other vehicle(s) involved, list type(s):

Where were you sitting?Front SeatBack SeatLeft SideRight SideMiddleUnusual Position

Which restraints were used? (Check all that apply)

LapShoulderCar SeatBooster SeatAir Bag

Speed of vehicle you were in:

Speed of other object or vehicle:

Did your vehicle hit another object?YesNo

Or did other vehicle hit your vehicle?YesNo

If yes, where was your vehicle hit?Head OnRear EndedToward FrontToward RearDrivers SidePassenger Side

Did you experience whiplash?YesNo

Did you hit your head?YesNo

If yes, on what?

Other Accidents

Type (ex Home Industrial Fall Hit by Object ,etc.)

Toxic

Type (ex: medication related, drug abuse, poison, etc.)

Anoxic

Type (ex: drowning, C02, anesthesia, cord around neck, etc.)

Vascular

Type (ex: stroke, aneurysm, hemorrhage, etc.)

Other

Please explain

Head Injury Description

What part of your head was affected?ForeheadBack of HeadRight SideLeft SideTop of headFace

Were you unconscious?YesNo

If so, for how long?

Comments

Initial Care

Did you see a doctor concerning the accident?YesNo

Whom did you see?

When?

Where?

What were you or your family told?

Comments

Subsequent/Other Professional Care

What kind of professional care for your injuries/trauma have you received or are you receiving?

Family Physician

Chiropractor

Neurologist

Neuropsychologist

Emergency Room Doctor

Occupational Therapist

Physical Therapist

Speech Therapist

Audiologist/Otolaryngologist

Psychologist

Physiatrist

Psychiatrist

Optometrist

Ophthalmologist

Osteopath

Massage Therapist

Other

Symptoms immediately following the accident

Double VisionBlurred VisionDizzinessDisorientationHeadachePain In or Around EyesRestrictive Field of ViewFlashes of LightLoss of MemoryVomitingLoss of BalanceRestricted Motion

Comments

Difficulties Following Accident

Work Related

Hobbies/Avocational

Recreational/Social

Other

Other Information

Please take the time to share with us anything else that you feel is relevant:

I authorize the release of medical and/or other information pertinent to my care to the insurance company in order for me to be reimbursed.

Signature:

Date:

Subsequent Symptoms/Experiences

Please consider each symptom and check that apply. Place check for MIN if the symptom is only minimally present or MAX if the symptom is very significant

Blurred Vision, Distance Viewing

Was present before accident - MINWas present before accident - MAXHad before accident and has worsened - MINHad before accident and has worsened - MAXNew symptom since accident - MINNew symptom since accident - MAX

Blurred Vision, Near Viewing

Slow to shift focus, near to far to near

Difficulty taking notes

Putting or tugging sensation around eyes

Difficulty moving or turning eyes

Pain with movement of the eyes

Wandering eye

Double Vision

Loss of place while reading

Discomfort while reading

Unable to sustain near work/reading for adequate periods

General fatigue while reading

Eyes get tired while reading

Headaches

Pain in or around eyes

Easily distracted

Decreased attention span

Reduced concentration ability

Difficulty remembering what has been read

Difficulty remembering names of objects

Difficulty remembering people's names

Difficulty recalling information known in the past

Difficulty recognizing formerly familiar objects

Difficulty recognizing formerly familiar people

Difficulty remembering things heard

Difficulty remembering things seen

Dizziness

Poor coordination

Clumsiness

Loss of balance

Poor eye-hand coordination

Poor handwriting

Poor posture

Head tilt

Face turn

Covering, closing one eye

Disorientation

Get lost often

Bothered by movement around you

Bothered by noises around you

Bothered by being touched

Abnormal general fatigue

Reduced depth perception

Light sensitivity

Flashes of light

Floaters in field of view

Restricted field of vision

Tunnel vision

"Curtain" billowing into field of view

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!Column 1

Our Location

11200 Highland Rd
Hartland, MI 48353

Contact Us

Phone: 810-632-5240
Fax: 810-632-2048

BOOK AN APPOINTMENT

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HOURS OF OPERATION

Monday: 9:30am-5pm
Tuesday: 7am-5pm
Wednesday: 7am-5pm
Thursday: 10am-7pm
Friday: 9:30am-1pm

!Column 3

SERVICES

Comprehensive Eye Exams
Eyeglass Consultations
Contact Lens Consultations & Fittings
Ocular Disease Diagnosis,
Treatment & Management
Myopia Management
Dry Eye Treatment
Orthokeratology
Neurolens Testing
Vision Therapy

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TBI (Traumatic Brain Injury) History Form

Type of Accident

Which restraints were used? (Check all that apply)

Other Accidents

Toxic

Anoxic

Vascular

Other

Head Injury Description

Initial Care

Subsequent/Other Professional Care

Symptoms immediately following the accident

Difficulties Following Accident

Other Information

I authorize the release of medical and/or other information pertinent to my care to the insurance company in order for me to be reimbursed.

Subsequent Symptoms/Experiences

Blurred Vision, Distance Viewing

Blurred Vision, Near Viewing

Slow to shift focus, near to far to near

Difficulty taking notes

Putting or tugging sensation around eyes

Difficulty moving or turning eyes

Pain with movement of the eyes

Wandering eye

Double Vision

Loss of place while reading

Discomfort while reading

Unable to sustain near work/reading for adequate periods

General fatigue while reading

Eyes get tired while reading

Headaches

Pain in or around eyes

Easily distracted

Decreased attention span

Reduced concentration ability

Difficulty remembering what has been read

Difficulty remembering names of objects

Difficulty remembering people's names

Difficulty recalling information known in the past

Difficulty recognizing formerly familiar objects

Difficulty recognizing formerly familiar people

Difficulty remembering things heard

Difficulty remembering things seen

Dizziness

Poor coordination

Clumsiness

Loss of balance

Poor eye-hand coordination

Poor handwriting

Poor posture

Head tilt

Face turn

Covering, closing one eye

Disorientation

Get lost often

Bothered by movement around you

Bothered by noises around you

Bothered by being touched

Abnormal general fatigue

Reduced depth perception

Light sensitivity

Flashes of light

Floaters in field of view

Restricted field of vision

Tunnel vision

"Curtain" billowing into field of view