First Name:
*
Last Name:
*
Street Address
*
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
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MO
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OR
PA
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TN
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UT
VT
VA
WA
WV
WI
WY
Zip
Work Phone:
Home/Cell Phone:
Email:
Date of Birth:
Grade:
School:
Date of Last Eye Exam:
Primary Vision Insurance:
Secondary Vision Insurance:
Primary Medical Insurance:
Secondary Medical Insurance:
How did you hear about our office?
I’m a returning Patient
Doctor Referral (Write name in box below)
Friend (Write name in box below)
Yellow Pages
Saw Sign / Building
Insurance listing
Web page
Other
Other:
Name of person who referred you:
MEDICAL HISTORY
HAS THE PATIENT (CHILD) HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?
Gastrointestinal
Yes
No
Not Sure
Ears/Nose/Throat
Yes
No
Not Sure
Cardiovascular
Yes
No
Not Sure
Respiratory
Yes
No
Not Sure
High Blood Pressure
Yes
No
Not Sure
Neurological
Yes
No
Not Sure
Urinary
Yes
No
Not Sure
Muscles/Bones
Yes
No
Not Sure
Skin
Yes
No
Not Sure
Eyes
Yes
No
Not Sure
Endocrine
Yes
No
Not Sure
Blood/Lymph
Yes
No
Not Sure
Allergic/Immunological
Yes
No
Not Sure
Headaches
Yes
No
Not Sure
Mental
Yes
No
Not Sure
List your medications followed by what they are for (ex. Insulin/Diabetes). Medication / Purpose:
Are you diabetic?
Yes
No
If yes, year of diagnosis:
Are you allergic to any medication?
Yes
No
Medications I am allergic too:
Name of Pediatrician:
Date of last visit:
List any surgeries:
FAMILY HISTORY
DOES ANY OF YOUR IMMEDIATE FAMILY HAVE ANY OF THESE CONDITIONS?
High Blood Pressure
Yes
No
Who?
Diabetes
Yes
No
Who?
Glaucoma
Yes
No
Who?
Macular Degeneration
Yes
No
Who?
Retinal Detachment
Yes
No
Who?
Cataracts
Yes
No
Who?
Father’s Prescription Nearsighted?
Yes
No
Mother’s Prescription Nearsighted?
Yes
No
The prevalence of nearsightedness has increased from 25% in the 1970’s to over 41% by 2004 (Arch Ophthalmol. 2009;127(12):1632-1639). Would you like information on how to prevent or limit nearsightedness?
Yes
No
PERSONAL EYE INFORMATION
Has the patient (child) had any eye surgeries, injuries or serious conditions?
Yes
No
If yes, please describe:
Does the patient (child) ever wear (check all that apply)?
Prescription Glasses
Prescription Sunglasses
Non Prescription Sunglasses
Soft Contact Lenses
Hard (Gas-permeable) contact lenses
Tell us why you are here today (check all that apply):
New Glasses
New Contacts
Eye Health problem
Eye Comfort problem
Academic problem
Other
Have any of your children had difficulty in school?
Yes
No
Briefly explain:
Visual skill and visual perceptual ability is critical to excellent performance in school. Please carefully review all these questions so we can enhance your child’s visual comfort and performance.
How do you feel your child is doing in school relative to their ability?
Well (School is very easy)
Below potential (They may get good grades but work harder than you would expect)
Poorly (Has many struggles – strong history of learning challenges)
Has your child ever had any additional help in school work such as (check all that apply):
Tutoring in (list subjects below):
Resource room
ADD medication
Special class
Special accommodations
Held back a year
Other
Tutoring subjects:
Other:
Please check the signs and symptoms that best describe how your child is doing in school:
Have headaches after doing school work?
Frequently awkward, bump into things, knock things over?
Read a great deal of the time?
Have trouble copying work from the chalkboard to paper?
Spend a long time doing homework that should take only a few minutes?
Reduced attention span, can concentrate for only a moderate time?
Covers one eye by leaning on hand?
Lays head on desk when doing pencil work?
Frequently loses place when reading?
Skips or re-reads words and lines?
Reverses words or letters (was for saw, b for d) beyond second grade?
Does better at math than English, history or social studies?
Must re-read material several times to grasp its meaning?
Gets tired quickly when doing reading or homework?
Short attention span? Can concentrate on reading work for only a few minutes.
Daydreams a lot? Stares off into the distance frequently?
Learns best through auditory tactics (listens to learn)?
Misbehavior has become a problem (to cover up poor school performance)?
Acts up when asked to do school work
Class clown, "goofs off"
Moody or depressed about school and life
Aggressive, hits or dominates other children
Avoids work that includes reading or near seeing?
Is more than 1 year behind group in reading-related skills?
RECREATION AND LEISURE
In what recreational activities does your child participate?
Read
Baseball
Basketball
Soccer
Swim
Build Models
Sew
Dance
Perform
Play an Instrument
Other recreational or sports activities?
Does your child wear protective eyewear for his/her sport?
Yes
No
Does your child use a computer at home?
Yes
No
Number of hours daily:
IS THERE ANYTHING WE FORGOT TO ASK?
Please tell us anything you would like us to know about your visit so that we can better serve you:
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