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Conveniently located at 470 Chrysler Dr., Unit 3

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Call 905-793-2020

Fax 905-793-8528

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Home » Contact Us » Patient Forms » MVA Online Form

MVA Online Form

HEAD INJURY/ABI PATIENT INFORMATION
Name*
First Last
Date of Birth
MM slash DD slash YYYY
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
OHIP #
Phone Number*
Emergency Contact
Relationship
Date of Loss
MM slash DD slash YYYY
Email Address*
How did you hear about us?
HEALTH HISTORY
Family 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 here
VISION/MVA RELATED QUESTIONS
Is 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 & SYMPTOMS
Please check the box if you have experienced any of the following since the time of the MVA/ABI
PHYSICAL
- 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

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Thompson Optometry

Unit 3, 470 Chrysler Dr
Brampton, ON L6S 0C1

Phone: 905-793-2020
Email: office@drrickthompson.ca
(Do not send personal health information by email.)

Hours

Monday: 8:30 AM - 5:30 PM
Tuesday: 8:30 AM - 5:30 PM
Wednesday: 8:30 AM - 5:30 PM
Thursday: 8:30 AM - 5:30 PM
Friday: 8:30 AM - 5:30 PM
Saturday: 8:30 AM - 3:00 PM
Sunday: Closed

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Insurance Information

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Thompson Family Optometry - Located at 470 Chrysler Dr. Unit 3, Brampton, ON L6S 0C1

Phone: 905-793-2020, Fax: 905 793-8528
https://www.drrickthompson.ca/

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