Child History Form

Step 1 of 4

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Child Info

Full Name*

Date of Birth*

MM slash DD slash YYYY

Age Now*

Address*

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

Father/Guardian Info

Full Name

Home Phone

Business Phone

Cell Phone

Occupation

Mother/Guardian Info

Full Name

Home Phone

Business Phone

Cell Phone

Occupation

Other Info

Siblings (age and sex)

Name of School*

Current grade/level

Teacher's Name

Referred By

Reason for referral

What do you expect to find out from the exam?*

Pediatrician's name/address*

Last medical exam

Medical problems?

Present medications

Allergies?

Family history of eye or health problems?

Present Situation

In what ways does your child seem to have difficulty?

How does your child complain about his or her vision?

Has anyone noticed an eye turn in or wander out?*

Yes

Which eye?*

Left

Right

Both

Does your child ever report any of the following?

Headaches*

Yes

When?*

Blurred Vision Far*

Yes

When?*

Blurred Vision Near*

Yes

When?*

Double Vision*

Yes

When?*

Eyes hurt or tired*

Yes

When?*

Light Sensitivity*

Yes

When?*

Have you ever noticed the following:

Holding Reading Close*

Yes

When?*

Holding Reading Further Away*

Yes

When?*

Closing One Eye?*

Yes

When?*

Covering One Eye?*

Yes

When?*

Eyes frequently reddened?*

Yes

When?*

Frequent styes?*

Yes

When?*

Excessive eye rubbing?*

Yes

When?*

Get lost in book? Unaware peripherally?*

Yes

When?*

Uses finger to follow words?*

Yes

When?*

Distorted posture when reading?*

Yes

When?*

Inability to see distant objects?*

Yes

When?*

Bumping into objects?*

Yes

When?*

Poor general coordination?*

Yes

When?*

Skips words or re-reads*

Yes

When?*

Reverses words/letters*

Yes

When?*

Moves lips while reading quietly*

Yes

When?*

Moves head while reading*

Yes

When?*

Tilting head when reading*

Yes

When?*

Does your child have a speech or language deficit?*

Yes

Has any attempt been made to correct it?*

Yes

By whom?*

Was therapy successful?*

Developmental History

Is the child adopted?*

Yes

Does the child know?*

Yes

Age when adopted*

Full term pregnancy?*

Yes

Normal birth?*

Yes

Any complications before, during or following delivery?*

Yes

Was the child exposed in utero to:

Drugs

Alcohol

Nicotine

Tobacco

Did the child crawl?*

Yes

At what age?*

At what age did the child:

Walk*

Say First Words*

Use Sentences*

When fatigued, child will:

Sag

Become irritable

Become excited

Under tension, is there any pattern of behavior, thumb sucking, etc.?

School

Age at time of entrance*

Does child like school?*

Yes

Favorite part?

Least favorite?

Describe the child's school work*

Average

Better than average

Below average

Have there been any school difficulties?

What subjects are easiest?

Most difficult?

Does test taking appear to cause anxiety?*

Yes

Has your child ever been retained?*

Yes

Which grade?*

How did the child react to retention?*

Does the school consider the child to have a learning problem?*

Yes

Does the school consider the child to have a discipline problem?*

Yes

Does the child like to read?*

Yes

Visual History

How long has difficulty been noticed?*

Previous Visual Examinations

Reason for Exam

Date of Exam

Doctor's Name

Results

Reason for Exam 2

Date of Exam 2

Doctor's Name 2

Results 2

Reason for Exam 3

Date of Exam 3

Doctor's Name 3

Results 3

Members of family who have had visual attention issues and why

Give a brief description of your child as a person*

As you complete this history questionnaire you will recognize the thoroughness with which your problem will be considered. The office examination will take up enough time to permit a very complete optometric investigation of the problem. Your child’s future deserves the fullest consideration that you as parents and we here in the office can provide. In order for us to keep costs down, payment is expected in full at the time of service. We do not accept assignment from insurance companies. All payments are between the patient and our office.

Consent*

I authorize the release of medical and/or other information pertinent to my child’s care to the Southeastern Indiana Vision Development Center to help facilitate proper care.

Parent/Guardian Name*

Date*