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Children's History Form

 

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready for you when you arrive. Required fields are marked with asterisks (*).

 

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Patient Information

Last Name: *

First Name: *

Preferred Name:

 

Parent's Name:

Parent's Phone #:

 

Street Address:

City:

State:

Zip:

 

Home Phone: *

Work Phone: *

Email Address: *

 

Date of Birth:

 
 

Pediatrician's Name:

Pediatrician's Address:

 

Were your eyes dilated?

Yes No

Child's Current Medications (dose & reason for taking):

Medication Allergies:

Whom may we thank for referring you?

 
 
 

Insurance Information

Name of Insured:

Relationship to Patient:

Subscriber's Address:
(if different than above)

Subscriber's Employer:

Subscriber's SS# or ID#:

Subscriber's Birthdate:

Vision Insurance Company:

   Policy Number:

   Group Number:

Major Medical Insurance Company:

   Policy Number:

   Group Number:

 

Eye History

Does your child have any of the following? If "Yes," please provide information.

Blurry vision

 

Yes No

 

Double vision

 

Yes No

 

Squints a lot

 

Yes No

 

Crossing or wandering of one or both eyes

 

Yes No

 

Rubs eyes excessively

 

Yes No

 

Doesn't seem to focus

 

Yes No

 

Poor reading comprehension

 

Yes No

 

Rapidly tires when reading

 

Yes No

 

Frequent headaches

 

Yes No

 

Closing or covering one eye when reading

 

Yes No

 

Tilts head when reading

 

Yes No

 

Loses place when reading or skips words / lines

 

Yes No

 

Re-reading of words of paragraphs

 

Yes No

 

Excessive head movements while reading

 

Yes No

 

Word and letter reversals

 

Yes No

 

Holds book very close when reading

 

Yes No

 

Handwriting is crooked or poorly spaced

 

Yes No

 

Poor copying abilities from chalkboard to desk

 

Yes No

 

Slow reaction time and poor timing in sports or play

 

Yes No

 

Poor depth perception / poor coordination in sports

 

Yes No

 

Burn, itch, red, tear, discharge

 

Yes No

 

An eye injury or surgery

 

Yes No

 

Any lazy eye / amblyopia

 

Yes No

 

 
 
 

School Performance / Behavior

Parents / teachers satisfied with child's school performance

 

Yes No

 

Poor attention skills / ADD or ADHD

 

Yes No

 

The child is labeled as "unmotivated", distractable or lazy

 

Yes No

 

Classroom behavior is disruptive / unsatisfactory

 

Yes No

 

Avoids visual tasks / good auditory learner

 

Yes No

 

The child can read but chooses not to

 

Yes No

 

 

Developmental and Health History

Child's Biological Mother

 

Length of pregnancy:

normal  premature  

 

Any complications during pregnancy or delivery?

Yes No

If yes, please explain:

 

Child's Development

 

Birth weight:

normal  low  

 

List any complications of child's development:

 

List any major illnesses, accidents, eye or head injuries that the child has had and the age they occured:

 
 

Medical Information / Review of Systems

Does your child currently have:

 

Allergies / Allergies to medicines

 

Yes No

 

Surgery / hospitalizations

 

Yes No

 

Cardiovascular / heart (High blood pressure, murmur, other)

 

Yes No

 

Breathing (Asthma, shortness of breath, other)

 

Yes No

 

Ear / Nose / Throat (Hearing loss, frequent sore throats, sinus)

 

Yes No

 

Gastrointestinal (food problems, diarrhea, vomiting, other)

 

Yes No

 

Endocrine (Diabetes, thyroid, growth, other)

 

Yes No

 

Urinary (Pain/discomfort, blood in urine, other)

 

Yes No

 

Skin (Unusual rashes, excess dryness, other)

 

Yes No

 

Musculoskeletal (Juvenile Rheumatoid Arthritis, other)

 

Yes No

 

Neurological (High fever, seizures, balance, other)

 

Yes No

 

Psychiatric / Social (Any behavior problems)

 

Yes No

 

General / Constitutional (Fever, weight loss / gain, other)

 

Yes No

 

Blood diseases (Bleeding disorders, sickle cell, other)

 

Yes No

 

Other conditions not noted above:

 

Yes No

 

 

Is there a family history of problems in the following areas? If so, please mark the relationship(s) to patient.

M=mother, F=father, S=sibling, GP=grandparent.

Amblyopia / Lazy eye

 

Yes No

M

F

S

GP

 

Eye turn / Strabismus

 

Yes No

M

F

S

GP

 

Myopia / Hyperopia as young child / infant

 

Yes No

M

F

S

GP

 

Color Vision defect

 

Yes No

M

F

S

GP

 

Glaucoma

 

Yes No

M

F

S

GP

 

Cataracts before age 40

 

Yes No

M

F

S

GP

 

Blindness

 

Yes No

M

F

S

GP

 

Tear duct problems

 

Yes No

M

F

S

GP

 

Other eye problems / diseases

 

Yes No

M

F

S

GP

 

High blood pressure / heart problems

 

Yes No

M

F

S

GP

 

Diabetes

 

Yes No

M

F

S

GP

 

Neurological diseases

 

Yes No

M

F

S

GP

 

Birth defects

 

Yes No

M

F

S

GP

 

Genetic or familial disorders

 

Yes No

M

F

S

GP

 

Cancer

 

Yes No

M

F

S

GP

 

Other medical condition not listed above

 

Yes No

M

F

S

GP

 

 

Thank you for filling out your Children's History Form. If you would like to fill out paperwork for another child, you can return to this form after submitting.

 

I have filled out this form as accurately as possible and am complete. *

 
 

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