MVA Online Form HEAD INJURY/ABI PATIENT INFORMATIONName* First Last Date of Birth MM slash DD slash YYYY Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country OHIP # Phone Number*Emergency Contact Relationship Date of Loss MM slash DD slash YYYY Email Address* How did you hear about us? HEALTH HISTORYFamily Doctor Any Hospitalizations List of Medications Do you have any allergies? Yes No please list them here Please check the box if you have any history of the following Glaucoma Cataracts Retinal Detachment Macular Degeneration Colour Blindness Diabetes Heart Problems Stroke Thyroid Condition Asthma Allergies Arthritis High Blood Pressure Do any of the listed items above run in your family? If so, please list them hereVISION/MVA RELATED QUESTIONSIs this your first visual examination? Yes No when was your last examination? Have you had any eye injuries in the past? Yes No please explain Have you had any eye surgeries? Yes No please explain Please check the box if you have experienced any of the following at the time of the MVA/ABI Eye Injury CT scan Closed head injury MRI Whip lash Cranial Sacral Therapy Unconscious Chiropractic Therapy Physiotherapy Please check the box if you get overwhelmed or anxious in any of the following situations Big box stores Public transit In large groups/ crowds Around loud noises Driving Do you currently have a valid driver’s license? Yes No Has your driver’s license ever been suspended? Yes No Do you work currently (part time or full time)? Yes No what barriers prevent you from working?VISUAL SIGNS & SYMPTOMSPlease check the box if you have experienced any of the following since the time of the MVA/ABIPHYSICAL Dry eyes Eye drops Burning eyes Eye turn Watery eyes Wandering eye Itchy eyes Eye pain Rubbing eyes Flashes/spots in vision Squinting Do you experience headaches? Yes No please explain Reading Lose place while reading Hold closely to read Skip or re-reads lines Print moves/jumps Falls asleep reading Eye strain Blur reading Headaches Double vision reading Dizziness Shuts one eye to read Nausea Trouble comprehending things I read Average reading time prior to the MVA/ABI? Average reading time after the MVA/ABI? Hand-Eye Coordination Poor hand writing/ printing Difficulty reaching for objects Reverses/ omits letters Difficulty catching balls Please describe your hand-eye coordination Distance Vision Eye strain Double vision distance Blur distance Trouble judging distance Vehicles appear in wrong lane Lighting Light sensitivity indoors Glare of lights at night Light sensitivity in sunlight Light induces headache Trouble seeing in dark areas Walking Bumps into things/people Trips over objects/curb Dizziness while moving Nausea while moving Lose balance while walking Ground does not appear level Need assistive device while walking (cane, walker, etc.) Standing/Sitting Feeling dizzy while still Objects move while still Incomplete image of objects Nausea while sitting Lose balance easily Nausea while standing Seeing objects or things that are not really there Other Loses belongings Easily distracted Poor memory/forgetful Poor concentration Dizzy while traveling (car) Nausea while traveling (car) Trouble comprehending things I see Trouble comprehending what I hear If you have any specific comments or questions for the doctor please list them here