Child Patient History & Registration

Child Patient History & Registration

Child Patient History & Registration

Child Patient History & Registration

CHILD PATIENT HISTORY & REGISTRATION

Name*

DOB*
Gender*
Preferred Pronoun
Grade Level
School Name
Address*
Siblings of Patient

Name
Age
1
2
3
4

Parent Information

Legal Parent/Guardian (I) Name
DOB
Cell Phone*
Home Phone*
Is this the same for the patient?
Email Address*
Employer
Occupation
Work Phone*
Is this a good day time number?
Legal Parent/Guardian (II) Name
DOB
Cell Phone*
Home Phone*
Is this the same for the patient?
Email Address*
Employer
Occupation
Work Phone*
Is this a good day time number?

Medical History

Pediatrician Name
Phone Number*
Date of Last Checkup
Has the child ever been diagnosed or treated for the following?
Please list the names of current medications (Rx and Over the Counter), including vitamins, eye drops, and birth control pills
Please list any allergies to medications, if applicable
Please list the conditions and relationship of relative
Has the child ever been hospitalized?
Was the child considered “difficult birth”?
Milestones

Eye History

Date of Last Eye Exam
Date of Last Eye Exam
Child wears glasses for
Child wears contacts for _ hours per day
Brand
Type
Has the child ever been diagnosed or treated for the following?
Does (child) have any blood relative with any of the previous conditions?
How did you hear about us?

Child Visual Skills Checklist

Patients Name

Age
Date
Parent's Names:
Parent's Names:
Symptoms (Please estimate how often the above-named exhibits the behaviors on this list.)
Complains of headaches, uncomfortable, or blurred vision
Comprehension reduces as reading continues
Squints or blinks excessively at desk or while reading
Holds reading material too closely, or holds face close to desk surface
Omits/inserts small words/loses place when reading
Uses a finger to keep his/her place while reading
Confuses minor differences in words when reading
Reverses letters or words in writing and copying
Writes crookedly, poorly spaced, or does not stay on ruled lines
Experiences trouble copying from the board
Experiences clumsiness or coordination issues
Sees double or covers 1 eye
Experiences eye crossing or wanders
Not working up to academic potential
Exhibits dizziness/balance problems

Signature

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES AT TIME OF SERVICE

Health Information Protection*
NAME OF RESPONSIBLE PARTY
RELATIONSHIP
Date
Helpful Articles

All Vision Therapy
Services

Learn More

Keep
In Touch

Contact Us
admin none 10:00 AM – 4:00 PM 9:00 AM – 6:00 PM 10:00 AM – 6:00 PM 9:00 AM – 6:00 PM By Appointment Only Closed Closed optometrist # # #