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 (*).

Patient Information

Last Name: *

First Name: *

Preferred Name:

Parent's Name:

Parent's Phone #:

Street Address:

City:

State:

Zip:

Home Phone: *

Cell Phone: *

Email Address: *

Date of Birth:

Pediatrician's Name:

Pediatrician's Address:

Were your eyes dilated?

Yes

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

Double vision

Yes

Squints a lot

Yes

Crossing or wandering of one or both eyes

Yes

Rubs eyes excessively

Yes

Doesn't seem to focus

Yes

Poor reading comprehension

Yes

Rapidly tires when reading

Yes

Frequent headaches

Yes

Closing or covering one eye when reading

Yes

Tilts head when reading

Yes

Loses place when reading or skips words / lines

Yes

Re-reading of words of paragraphs

Yes

Excessive head movements while reading

Yes

Word and letter reversals

Yes

Holds book very close when reading

Yes

Handwriting is crooked or poorly spaced

Yes

Poor copying abilities from chalkboard to desk

Yes

Slow reaction time and poor timing in sports or play

Yes

Poor depth perception / poor coordination in sports

Yes

Burn, itch, red, tear, discharge

Yes

An eye injury or surgery

Yes

Any lazy eye / amblyopia

Yes

School Performance / Behavior

Parents / teachers satisfied with child's school performance

Yes

Poor attention skills / ADD or ADHD

Yes

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

Yes

Classroom behavior is disruptive / unsatisfactory

Yes

Avoids visual tasks / good auditory learner

Yes

The child can read but chooses not to

Yes

Developmental and Health History

Child's Biological Mother

Length of pregnancy:

normal

premature

Any complications during pregnancy or delivery?

Yes

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

Surgery / hospitalizations

Yes

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

Yes

Breathing (Asthma, shortness of breath, other)

Yes

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

Yes

Gastrointestinal (food problems, diarrhea, vomiting, other)

Yes

Endocrine (Diabetes, thyroid, growth, other)

Yes

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

Yes

Skin (Unusual rashes, excess dryness, other)

Yes

Musculoskeletal (Juvenile Rheumatoid Arthritis, other)

Yes

Neurological (High fever, seizures, balance, other)

Yes

Psychiatric / Social (Any behavior problems)

Yes

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

Yes

Blood diseases (Bleeding disorders, sickle cell, other)

Yes

Other conditions not noted above:

Yes

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

Eye turn / Strabismus

Yes

Myopia / Hyperopia as young child / infant

Yes

Color Vision defect

Yes

Glaucoma

Yes

Cataracts before age 40

Yes

Blindness

Yes

Tear duct problems

Yes