Date* Current diagnosis:*Patient’s Name:* First Last Gender:* Male Female Date of Birth:* Age:*Grade:*Please evaluate for:* Perceptual, Struggling in school Strabismus (Eye Turn) , Amblyopia (Lazy Eye) Tracking Difficulties Convergence Insufficiency Head Injury / Stroke Acquired Diplopia, Nerve Palsy, Multiple Sclerosis Sports Vision Therapy Myopia Control Developmental, Cerebral Palsy, Austism Referring Practice Contact InformationPractice Name:*Referring Doctor/Therapist:*Address* Street Address Address Line 2 City State / Province / Region Phone #:*Fax #:*Parent/Patient Contact InformationAdults Name:*Relationship to Patient:*Address* Street Address Address Line 2 City State / Province / Region Phone Number (Hm):*(Cell/Wk)*Insurance:*Insurance ID#:*Patient’s School:*Children’s Checklist:* Yes No Last Eye Exam Faxed:* Yes No