Child History Form Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Work Phone:Home/Cell Phone:(Required)Email(Required) Date of Birth:(Required) MM slash DD slash YYYY Grade: School: Date of Last Eye Exam:(Required) MM slash DD slash YYYY Financially Responsible Individual Primary Vision Insurance:(Required) Insurance ID Number(Required) Name of Subscriber(Required) Primary Medical Insurance:(Required) Insurance ID Number(Required) Name of Subscriber(Required) Do You Have Secondary Vision Insurance? No Yes Secondary Vision Insurance: Insurance ID Number Name of Subscriber Do You Have Secondary Medical Insurance? No Yes Secondary Medical Insurance: Insurance ID Number Name of Subscriber How did you hear about our office?(Required) 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: (Required) Name of person who referred you: MEDICAL HISTORY HAS THE PATIENT (CHILD) HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?Gastrointestinal(Required) Yes No Not Sure Ears/Nose/Throat(Required) Yes No Not Sure Cardiovascular(Required) Yes No Not Sure Respiratory(Required) Yes No Not Sure High Blood Pressure(Required) Yes No Not Sure Neurological(Required) Yes No Not Sure Urinary(Required) Yes No Not Sure Muscles/Bones(Required) Yes No Not Sure Skin(Required) Yes No Not Sure Eyes(Required) Yes No Not Sure Endocrine(Required) Yes No Not Sure Blood/Lymph(Required) Yes No Not Sure Allergic/Immunological(Required) Yes No Not Sure Headaches(Required) Yes No Not Sure Mental(Required) Yes No Not Sure List your medications followed by what they are for (ex. Insulin/Diabetes). Medication / Purpose Add RemoveAre you diabetic?(Required) Yes No year of diagnosis:Are you allergic to any medication?(Required) Yes No Medications I am allergic too: Name of Pediatrician:(Required) First Last Date of last visit: MM slash DD slash YYYY List any surgeries: Add RemoveFAMILY HISTORY - DOES ANY OF YOUR IMMEDIATE FAMILY HAVE ANY OF THESE CONDITIONS?High Blood Pressure(Required) Yes No Who? Diabetes(Required) Yes No Who? Glaucoma(Required) Yes No Who? Macular Degeneration(Required) Yes No Who? Retinal Detachment(Required) Yes No Who? Cataracts(Required) Yes No Who? Father’s Prescription Nearsighted?(Required) Yes No Mother’s Prescription Nearsighted?(Required) 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 INFORMATIONHas the patient (child) had any eye surgeries, injuries or serious conditions?(Required) Yes No 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):(Required) New Glasses New Contacts Eye Health problem Eye Comfort problem Academic problem Other: Have any of your children had difficulty in school?(Required) 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?(Required) 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 (circle all that apply):(Required) Tutoring in Resource room ADD medication Special class Special accommodations Held back a year Other Tutoring in(list subjects): Please check the signs and symptoms that best describe how your child is doing in school(Required) 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 LEISUREIn what recreational activities does your child participate?(Required) 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?(Required) Yes No Number of hours dailyIS 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:
