New Patient Questionnaire – Child – Online Name First Middle Last Gender Male Female Birth Date MM slash DD slash YYYY Age Years Months Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberPlease list the names and birth dates of your familyFather/Caretaker Birth Date MM slash DD slash YYYY Mother/Caretaker Birth Date MM slash DD slash YYYY Sibling Birth Date MM slash DD slash YYYY Sibling Birth Date MM slash DD slash YYYY Sibling Birth Date MM slash DD slash YYYY Sibling Birth Date MM slash DD slash YYYY Whom may we thank for your referral to our office? SCHOOL INFORMATIONName Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Grade Teacher School Nurse Principal Child’s dominant hand? Right Left Has guidance been given in use of hand? Yes No MEDICAL HISTORYPediatrician’s Name Date of Last Evaluation MM slash DD slash YYYY For what reason? Results and recommendationsChild’s current state of health Is your child especially afraid of doctors? Medications currently using, including vitamins and supplementsFor what condition(s)? Immunizations child has receivedImmunization typeDateImmunization typeDateImmunization typeDateImmunization typeDateAny reactions to immunization(s)? Yes No If yes, explain List illnesses, bad falls, high fevers, etcIs you child generally healthy? Yes No Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No If yes, please list Has a neurological evaluation been performed? Yes No By whom? Results and recommendations Has a psychological evaluation been performed? Yes No By whom? Results and recommendations Has an occupational therapy evaluation been performed? Yes No By whom? Results and recommendations Is there any history of the following? (please check if there is a history)Diabetes Patient Family Who ? “Cross” or “Wall” eye Patient Family Who ? Chromosomal Imbalance Patient Family Who ? Glaucoma Patient Family Who ? High Blood Pressure Patient Family Who ? Learning Disability Patient Family Who ? Amblyopia (lazy eye) Patient Family Who ? Multiple Sclerosis Patient Family Who ? Epilepsy or Seizures Patient Family Who ? Other NUTRITIONAL INFORMATIONCurrent Diet Excellent Good Fair Poor Does your child Like sweets crave sweets Is your child active? Yes No Moderately Extremely Are there periods of very high energy? Yes No Are there periods of very low energy? Yes No Explain DEVELOPMENTAL HISTORYFull term pregnancy? Yes No If no then at what week was delivery? Did the mother experience any health problems during the pregnancy? Yes No If yes, explain Normal birth? Yes No Any complications before, during or immediately following delivery? Yes No If yes, explain: Birth Weight Apgar scores at birth After 10 minutes Were forceps used? Yes No Was there ever any reason for concern over your child’s general growth or development? Yes No If yes, why? Did your child crawl (stomach on floor)? Yes No At what age? Did your child creep (on all fours)? Yes No At what age? If not describe At what age did your child walk? Was child active Yes No Speech: First words Yes No At what age Was speech clear to others? Yes No Is speech clear now? Yes No VISUAL HISTORYHas your child’s vision been previously evaluated? Yes No If so, Doctor’s Name Date of last evaluation MM slash DD slash YYYY Reason for examination Results and recommendations Were glasses, contact lenses, or other optical devices recommended? Yes No If yes, what? Are they used? Yes No If yes, when? If not used, why not? Members of the family who have had visual attention and the reason:NameAgeVisual Situation PRESENT SITUATIONWhy do you feel your child needs a visual evaluation? How long has the problem/difficulty been observed? Is there any evidence from the school, psychological, or other tests that indicates some visual malfunction may be present? Yes No If yes, what? Does your child report any of the following?Headaches Yes No If yes, when? Blurred vision/focus goes in and out Yes No If yes, when? Double vision Yes No If yes, when? Eyes hurt Yes No If yes, when? Eyes tired Yes No If yes, when? Words move around on the page Yes No If yes, when? Motion Sickness/car sickness Yes No If yes, when? Dizziness Yes No If yes, when? List any other complaints your child makes concerning his/her visionHAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWINGEyes frequently reddened Yes No If yes, when? Frequent eye rubbing Yes No If yes, when? Frequent styes Yes No If yes, when? Frowning Yes No If yes, when? Bothered by light Yes No If yes, when? Frequent blinking Yes No If yes, when? Closing or covering one eye Yes No If yes, when? Difficulty seeing distant objects Yes No If yes, when? Head close to paper when reading or writing Yes No If yes, when? Avoids reading Yes No If yes, when? Prefers being read to Yes No If yes, when? Tilts head when reading Yes No If yes, when? Tilts head when writing Yes No If yes, when? Moves head when reading Yes No If yes, when? Confuses letter or words Yes No If yes, when? Reverses letter or words Yes No If yes, when? Confuses left and right Yes No If yes, when? Skips, rereads or omits words Yes No If yes, when? Loses place while reading Yes No If yes, when? Vocalizes when reading silently Yes No If yes, when? Reads slowly Yes No If yes, when? Uses finger as a marker Yes No If yes, when? Poor reading comprehension Yes No If yes, when? Comprehension decreases over time Yes No If yes, when? Writes or prints poorly Yes No If yes, when? Writes neatly but slowly Yes No If yes, when? Does not support paper when writing Yes No If yes, when? Awkward or immature pencil grip Yes No If yes, when? Frequent erasures Yes No If yes, when? Tires easily Yes No If yes, when? Difficulty copying from chalkboard Yes No If yes, when? Writes up/down hill Yes No If yes, when? Misaligns digits/columns of numbers Yes No If yes, when? Clumsy, knocks things over Yes No If yes, when? Does not use his/her time well Yes No If yes, when? Loses belongings/things Yes No If yes, when? Untitled
