Name

First Middle Last

Gender

Male
Female

Birth Date

Age

Years

Months

Address

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

Phone Number

Please list the names and birth dates of your family

Father/Caretaker

Birth Date

Mother/Caretaker

Birth Date

Sibling

Birth Date

Sibling

Birth Date

Sibling

Birth Date

Sibling

Birth Date

Whom may we thank for your referral to our office?

SCHOOL INFORMATION

Name

Address

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

Grade

Teacher

School Nurse

Principal

Child’s dominant hand?

Right
Left

Has guidance been given in use of hand?

Yes
No

MEDICAL HISTORY

Pediatrician’s Name

Date of Last Evaluation

For what reason?

Results and recommendations

Child’s current state of health

Is your child especially afraid of doctors?

Medications currently using, including vitamins and supplements

For what condition(s)?

Immunizations child has received

Immunization type	Date

Immunization type	Date

Immunization type	Date

Immunization type	Date

Any reactions to immunization(s)?

Yes
No

If yes, explain

List illnesses, bad falls, high fevers, etc

Is 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 INFORMATION

Current 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 HISTORY

Full 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 HISTORY

Has your child’s vision been previously evaluated?

Yes
No

If so, Doctor’s Name

Date of last evaluation

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:

Name	Age	Visual Situation

PRESENT SITUATION

Why 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 vision

HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING

Eyes 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

New Patient Questionnaire – Child – Online

Please list the names and birth dates of your family

SCHOOL INFORMATION

MEDICAL HISTORY

Is there any history of the following? (please check if there is a history)

NUTRITIONAL INFORMATION

DEVELOPMENTAL HISTORY

VISUAL HISTORY

PRESENT SITUATION

Does your child report any of the following?

HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING

Strengthen Your Eyes
Not Just Your Glasses

Please list the names and birth dates of your family

SCHOOL INFORMATION

MEDICAL HISTORY

Is there any history of the following? (please check if there is a history)

NUTRITIONAL INFORMATION

DEVELOPMENTAL HISTORY

VISUAL HISTORY

PRESENT SITUATION

Does your child report any of the following?

HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING

Strengthen Your Eyes Not Just Your Glasses

Strengthen Your Eyes
Not Just Your Glasses