New Patient Questionnaire – Child – Online Name First Middle Last GenderMaleFemaleBirth Date Date Format: MM slash DD slash YYYY AgeYearsMonthsAddress 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/CaretakerBirth Date Date Format: MM slash DD slash YYYY Mother/CaretakerBirth Date Date Format: MM slash DD slash YYYY SiblingBirth Date Date Format: MM slash DD slash YYYY SiblingBirth Date Date Format: MM slash DD slash YYYY SiblingBirth Date Date Format: MM slash DD slash YYYY SiblingBirth Date Date Format: MM slash DD slash YYYY Whom may we thank for your referral to our office?SCHOOL INFORMATIONNameAddress 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 GradeTeacherSchool NursePrincipalChild’s dominant hand?RightLeftHas guidance been given in use of hand?YesNoMEDICAL HISTORYPediatrician’s NameDate of Last Evaluation Date Format: MM slash DD slash YYYY For what reason?Results and recommendationsChild’s current state of healthIs 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)?YesNoIf yes, explainList illnesses, bad falls, high fevers, etcIs you child generally healthy?YesNoAre there any chronic problems like ear infections, asthma, hay fever, allergies?YesNoIf yes, please listHas a neurological evaluation been performed?YesNoBy whom?Results and recommendationsHas a psychological evaluation been performed?YesNoBy whom?Results and recommendationsHas an occupational therapy evaluation been performed?YesNoBy whom?Results and recommendationsIs there any history of the following? (please check if there is a history)DiabetesPatientFamilyWho ?“Cross” or “Wall” eyePatientFamilyWho ?Chromosomal ImbalancePatientFamilyWho ?GlaucomaPatientFamilyWho ?High Blood PressurePatientFamilyWho ?Learning DisabilityPatientFamilyWho ?Amblyopia (lazy eye)PatientFamilyWho ?Multiple SclerosisPatientFamilyWho ?Epilepsy or SeizuresPatientFamilyWho ?OtherNUTRITIONAL INFORMATIONCurrent DietExcellentGoodFairPoorDoes your childLike sweetscrave sweetsIs your child active?YesNoModeratelyExtremelyAre there periods of very high energy?YesNoAre there periods of very low energy?YesNoExplainDEVELOPMENTAL HISTORYFull term pregnancy?YesNoIf no then at what week was delivery?Did the mother experience any health problems during the pregnancy?YesNoIf yes, explainNormal birth?YesNoAny complications before, during or immediately following delivery?YesNoIf yes, explain:Birth WeightApgar scores at birthAfter 10 minutesWere forceps used?YesNoWas there ever any reason for concern over your child’s general growth or development?YesNoIf yes, why?Did your child crawl (stomach on floor)?YesNoAt what age?Did your child creep (on all fours)?YesNoAt what age?If not describeAt what age did your child walk?Was child activeYesNoSpeech: First wordsYesNoAt what ageWas speech clear to others?YesNoIs speech clear now?YesNoVISUAL HISTORYHas your child’s vision been previously evaluated?YesNoIf so, Doctor’s NameDate of last evaluation Date Format: MM slash DD slash YYYY Reason for examinationResults and recommendationsWere glasses, contact lenses, or other optical devices recommended?YesNoIf yes, what?Are they used?YesNoIf 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?YesNoIf yes, what?Does your child report any of the following?HeadachesYesNoIf yes, when?Blurred vision/focus goes in and outYesNoIf yes, when?Double visionYesNoIf yes, when?Eyes hurtYesNoIf yes, when?Eyes tiredYesNoIf yes, when?Words move around on the pageYesNoIf yes, when?Motion Sickness/car sicknessYesNoIf yes, when?DizzinessYesNoIf yes, when?List any other complaints your child makes concerning his/her visionHAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWINGEyes frequently reddenedYesNoIf yes, when?Frequent eye rubbingYesNoIf yes, when?Frequent styesYesNoIf yes, when?FrowningYesNoIf yes, when?Bothered by lightYesNoIf yes, when?Frequent blinkingYesNoIf yes, when?Closing or covering one eyeYesNoIf yes, when?Difficulty seeing distant objectsYesNoIf yes, when?Head close to paper when reading or writingYesNoIf yes, when?Avoids readingYesNoIf yes, when?Prefers being read toYesNoIf yes, when?Tilts head when readingYesNoIf yes, when?Tilts head when writingYesNoIf yes, when?Moves head when readingYesNoIf yes, when?Confuses letter or wordsYesNoIf yes, when?Reverses letter or wordsYesNoIf yes, when?Confuses left and rightYesNoIf yes, when?Skips, rereads or omits wordsYesNoIf yes, when?Loses place while readingYesNoIf yes, when?Vocalizes when reading silentlyYesNoIf yes, when?Reads slowlyYesNoIf yes, when?Uses finger as a markerYesNoIf yes, when?Poor reading comprehensionYesNoIf yes, when?Comprehension decreases over timeYesNoIf yes, when?Writes or prints poorlyYesNoIf yes, when?Writes neatly but slowlyYesNoIf yes, when?Does not support paper when writingYesNoIf yes, when?Awkward or immature pencil gripYesNoIf yes, when?Frequent erasuresYesNoIf yes, when?Tires easilyYesNoIf yes, when?Difficulty copying from chalkboardYesNoIf yes, when?Writes up/down hillYesNoIf yes, when?Misaligns digits/columns of numbersYesNoIf yes, when?Clumsy, knocks things overYesNoIf yes, when?Does not use his/her time wellYesNoIf yes, when?Loses belongings/thingsYesNoIf yes, when?Untitled
