Date:

Name:

First Last

Date of Birth:

Date of Accident / Trauma:

Describe the Accident / Trauma:

For Motor Vehicle Accidents:

Type of Vehicle Driving:

Other Vehicles Involved:

Where were you sitting:

Driver’s Seat
Front Passenger

Was a seatbelt worn:

Yes
No

Speed of your vehicle at time of accident:

Speed of other vehicle or object:

Did you hit another vehicle:

Yes
No

Did another vehicle hit you:

Yes
No

Did you hit your head:

Yes
No

For Non-Motor Vehicle Accidents:

Type of accident (fall, stroke, hit by object, etc.):

What part of the head was injured / affected:

Forehead
Back of head
Right side
Left side
Top of head
Face
Other

If other, please specify:

Any loss of consciousness?

Yes
No

If yes, how long:

Initial / previous care:

Did you see a doctor concerning your accident:

Yes
No

Who did you see:

When & where:

What did they tell you?

Name & Address of other professional care:

Family physician:

Neurologist:

Neuropsychologist:

Chiropractor:

Occupational Therapist:

Physical Therapist:

Speech Therapist:

Audiologist/Otolaryngologist:

Psychologist:

Psychiatrist:

Pysiatrist:

Optometrist:

Ophthalmologist:

Massage Therapist:

Other:

I authorize my doctors at Eye Vision Associates to release my medical information and reports to the doctors I have listed above:

Name:

First Last

Date:

Signature:

Symptoms following your accident:

Other symptoms:

Difficulties following accident:

Work related:

Hobbies:

Recreational:

Other:

CAPTCHA

Head Trauma Case History

For Motor Vehicle Accidents:

For Non-Motor Vehicle Accidents:

Initial / previous care:

Name & Address of other professional care:

Difficulties following accident:

Q&A with Dr. Meltzer

Dr. Bradley Meltzer Answers Your Eyecare Questions

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