Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

First Middle Last

Nickname

Birth Sex

Male
Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Please provide a telephone number, with area code, so we can contact you.

Home Phone

Please provide a telephone number, with area code, so we can contact you.

Email

Please provide us your email address.

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employer/School Name

Pronoun

Gender Identinty

Marital Status

Misc/Guardian

Emergency Contact Info

Personal Information

Gender*

Female
Male

Date of Birth*

Race*

Ethnicity*

Marital Status

Employment Status

Employer

Occupation

Primary Vision Insurance

Insurance Information

Insurance Name

Insurance Plan

Insurance ID

Insurance Policy Group

Not Primary on Account

Not Primary

Policy Holder Information

Primary Medical Insurance

Insurance Name

Insurance Plan

Insurance ID

Insurance Policy Group

Not Primary on Account

Not Primary

Policy Holder Information

Eye History

Legal Guardian Information

Name

First Middle Last

Relationship to patient

Date of Birth

Age

Sex

Male
Female

Street Address

Street Address City State / Province / Region ZIP / Postal Code Country

Social Security Number

Cell Phone

What is the main reason for your visit today?

Do you currently have symptoms

Do you currently take any eye medications?

Please list any eye surgeries and/or trauma (include dates)

Last exam

By Doctor or Ophthalmologist?

Last Visit

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Do you wear contacts?*

Contact Lens Wears Only

What solution do you use?

Do you have backup glasses?

How often do you sleep in your contacts?

How often do you replace contacts?

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Unknown family eye history

Family eye history

Medical History

Please list all medications

No Medications

No Medications

Please list all drug allergies

No Known drug allergies

No Known drug allergies

Vitamins

Over the counter medictions

Please describe any injuries or surgeries you have had:

Primary Care Physician

Last visit

Reason

Pregnant / Nursing

Do you have any of these medical conditions?

Other

If yes, please specify

Family Medical History

Unknown family history

Unknown family history

Does anyone in your family have these medical conditions?

Other

If yes, please specify

Review of systems

Social History

Hobbies

Drugs use

Type

How long

Illegal drug use

Type

Race

Ethnicity

Preferred language

STDs

Medical History

Is your child especially afraid of Doctors

Yes
No

Is your child generally healthy?

List significant illnesses, bad falls, high fevers or chronic illness

List all Illnesses, bad falls, high fever or chronic illnesses

Event/Condition, Age, Severity, Complications

Nuero / Psych Eval

Yes
No

By Whom?

Occupational Therapy Eval

Yes
No

By Whom?

Developmental History

Please bring all insurance cards with you to your appointment.

Length of pregancy

Type of delivery

Forceps/Vacuum
Anesthesia

During pregnancy of this child, did any of the following occur?

Other

Please Explain

Child's birth weight

Apgar Score at birth

@birth

After 10 minutes

My child is

Other

Explain

Skills / Milestones

Roll over 3.5 Months

Yes
No

Sits w/ out support 6.5 months

Yes
No

Walks unaided/alone 12 months

Yes
No

Kicks a ball 18 months

Yes
No

Toilet trained 24 months

Yes
No

Rides tricycle 3 Years

Yes
No

Reaches / grasp for object 4 months

Yes
No

Scribbles spontaneously 15 months

Yes
No

Stacks / Pile blocks 18 months

Yes
No

Eats with a fork / spoon 3 years

Yes
No

Smiles spontaneously 1 month

Yes
No

Says single words 12 months

Yes
No

Refers to self by first name 18 months

Yes
No

Knows full name 3 years

Yes
No

How is your child performing compared to others his/her age

How well developed is your child's spoken vocabulary?

Has your child undergone any of the following testing/treatment/therapy?

Educational

Yes
No

Nuerological

Yes
No

Psychological

Yes
No

Occupation

Yes
No

Speech/Auditory

Yes
No

Physical

Yes
No

If yes, please list all previous evaluations done on your child

Current grade in school

School

What is their favourite subject?

Visual History

Main reason to have an examination today

Last date of examination

Doctor's name

Reason for examination

Results or recommendations

Were glasses or contacts recommended?

Are they used and when?

If not. why not?

Do you observe or does your child report any of the following?

Are there other complications your child makes concerning vision?

Do you have any other concerns/observations concerning your child's vision?

Strabismus / Amblyopia History

At what age was the eye turn first noticed?

Did it start suddenly or gradually

Which direction does the eye turn?

In
Out
Up
Down

Which eye turns

Right
Left
Both

Is the eye turn getting worse, better or no change?

When does the eye turn (always, what % of time, when tired, when ill, etc)?)

Does the eye turn more when looking?

Do you ever notice one or both eyes shaking rapidly?

If patching treatment was prescribed, please describe at what age patching was started, how it was done, the eye patched, for how long, and an estimate of the results

Any surgery, estimate results

If yes, estimate the results

Please describe any visual therapy, including duration of treatment, age at which it was started an estimate the results:

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New Patient Child/Vision Therapy