Pediatric Service

Eye Health & Medical History

Patient’s Name:______Sex: M F Date of Birth:______Age:______

Address:______City:______State______Zip:______

Parent/Responsible Party:______Email: ______

Phone (H):______Phone (Cell):______Text reminder ok? Y / N

School Name:______Grade: ______Hobbies (computer/sports): ______Reason for visit/concerns noted by observing child:____________

Whom may we thank for referring you? (Website, Insurance, Friend)______

Ocular History

Date of last exam (not by school):______

By Whom:______

Yes No

Does your child wear glasses…...…. ______

For Distance Near Other

Date Prescribed:______

Contact Lenses…………………….. ______

Has child had vision therapy………. ______

Has child had patching…………….. ______

Does your child experience any of the following?

Blurred vision……………………… ______

Double vision……………………… ______

Eyestrain or fatigue………………… ______

Headache…………………………… ______

Eye pain……………………………. ______

Eye Disease………………………… ______

Cataracts…………………………… ______

Medical History

Last Medical Exam______

Pediatrician name & location______

______

Pharmacy______

Weight______Height______

Does child presently have problems with the following areas?

Yes No

Allergies, immune system……….. ______

Sinus, ears, nose…………………. ______

Respiratory (lungs, breathing, TB) ______

Cardiovascular (heart)…………… ______

Stomach, Colon…………………. ______

Neurological (seizure)………….. ______

Bones, Joints, arthritis, muscles… ______

Hepatitis………………………… ______

Endocrine (diabetes, thyroid)…… ______

Skin (eczema)…………………… ______

Blood disorders…………………. ______

Behavioral, depression…………. ______

Head injury…………………….. ______

Dizziness/Vertigo………………. ______

Poor Coordination……………… ______

Difficulty in attention…………… ______

Memory Problems………………. ______

Yes No

Burn, itch, tearing……………… ______

Lazy/wandering eye(left or right) ______

Flashes of light/floaters………… ______

Light sensitivity………………... ______

Loss of field of vision/restricted.. ______

Drooping of eyelid…………….. ______

Difficulty tracking an object…… ______

Squinting………………………. ______

Frequent blinking……………… ______

Redness………………………… ______

White appearance in pupil……… ______

Eye turning in/out………………. ______

Covers or closes an eye………… ______

Rubs eyes………………………. ______

Dryness…………………………. ______

Discharge from eyes……………. ______

Uncomfortable/inefficient reading ______

Blurred/uncomfortable vision with

Computer use…………………… ______

Does your child have a history of any of the following?

Yes No

Glaucoma………………………….. ______

Brain injury……………………….. ______

Ear infections……………………… ______

Eye surgery………………………… ______

Eye injury…………………………. ______

Please list all current medications:

______

Please list all environmental or medication allergies: ______

Family History (If yes, please indicate which family member and either maternal or paternal.)

Wears glasses………… Y/N Relation ______

Lazy Eye…………. ……Y/N Relation ______

Wandering Eye………….Y/N Relation______

Glaucoma……………… Y/N Relation ______

Macular Degeneration… Y/N Relation ______

Blindness………………. Y/N Relation ______

Diabetes…………………Y/N Relation______

High Blood Pressure…… Y/N Relation______

Cardiovascular disease….Y/N Relation______

Neurological disease…… Y/N Relation______

Patient Birth and Development History

To the Parent (or Guardian): Information about your child’s general health and development is essential in our care of your child. Please complete the questions that follow.

Birth History: During pregnancy, was there any use of medication, alcohol, cigarettes, or illicit drugs? yes no

If yes, please explain______

Birth wt______lbs______oz Full term: yes no If no, how many weeks premature?______

C-section? yes no Any need for oxygen after birth? yes no If yes, how long?______

Any complications before, during, or immediately following delivery? yes no

If yes, please explain______

Parents ages at time of birth:______Mother______Father

General Development: Please indicate at approximately what age the child was able to do the following:

______Begin to crawl ______Tie shoes ______Button clothes

______Walk ______Catch a ball ______Pick up objects

______Speak single words ______Speak short sentences (3 words)

______Sit ______Stand ______Roll Over

The following questions apply to school-aged children only:

Does the child have a hearing problem? ____yes _____no

Does the child have a speech problem? ____yes _____no

Is there a problem with attention or discipline? ____yes _____no

Has the child received any of the following services?

Yes No If yes, please explain

Speech therapy ______

Occupational therapy ______

Physical therapy ______

Developmental therapy ______

Education: Please check any of the following that are true about your child’s performance:

_____School suggests testing to rule out vision problems causing academic problems

_____Errors in copying from blackboard to paper

_____Avoids near work (reading/writing), or fails to complete work in allotted time

_____Poor reading comprehension

_____Reads below grade level

_____Tilts or turns head excessively during visual tasks

_____School performance not up to potential

_____Poor handwriting/printing

_____Poor spelling ability

_____Reverses letters when reading or writing

When reading, does the child:

_____Confuse similar words _____Use finger or marker to keep place

_____Often lose place, skip, or reread words or letters _____Complain of blurred vision

_____Complain of headaches _____Complain of print “running together” or “moving around”

_____Says eyes hurt, burn, or tire

Has the child had special education testing/received tutoring services? _____yes _____no

Has the child had an IEP (individual education plan) established? _____yes _____no

Best school subject:______Worst school subject: ______

Have there been consultations with doctors or specialists (i.e. neurologists, psychologists) with reference to schoolwork? _____yes _____no

If yes, please discuss______

Have any other family members had academic or school-related problems? _____yes _____no

If yes, please discuss______

I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of my child’s eyes and vision. I also acknowledge that I have read the Privacy Act Form (please ask for a copy if you have not already read it previously)

______

Parent/Guardian Signature Date Initialed by Dr.______