Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready for you when you arrive. Required fields are marked with asterisks (*).
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Does your child have any of the following? If "Yes," please provide information.
Crossing or wandering of one or both eyes
Poor reading comprehension
Rapidly tires when reading
Closing or covering one eye when reading
Loses place when reading or skips words / lines
Re-reading of words of paragraphs
Excessive head movements while reading
Word and letter reversals
Holds book very close when reading
Handwriting is crooked or poorly spaced
Poor copying abilities from chalkboard to desk
Slow reaction time and poor timing in sports or play
Poor depth perception / poor coordination in sports
Burn, itch, red, tear, discharge
School Performance / Behavior
Parents / teachers satisfied with child's school performance
Poor attention skills / ADD or ADHD
The child is labeled as "unmotivated", distractable or lazy
Classroom behavior is disruptive / unsatisfactory
Avoids visual tasks / good auditory learner
The child can read but chooses not to
Developmental and Health History
Child's Biological Mother
Length of pregnancy:
Any complications during pregnancy or delivery?
If yes, please explain:
List any complications of child's development:
List any major illnesses, accidents, eye or head injuries that the child has had and the age they occured:
Medical Information / Review of Systems
Does your child currently have:
Allergies / Allergies to medicines
Surgery / hospitalizations
Cardiovascular / heart (High blood pressure, murmur, other)
Breathing (Asthma, shortness of breath, other)
Ear / Nose / Throat (Hearing loss, frequent sore throats, sinus)
Gastrointestinal (food problems, diarrhea, vomiting, other)
Endocrine (Diabetes, thyroid, growth, other)
Urinary (Pain/discomfort, blood in urine, other)
Skin (Unusual rashes, excess dryness, other)
Musculoskeletal (Juvenile Rheumatoid Arthritis, other)
Neurological (High fever, seizures, balance, other)
Psychiatric / Social (Any behavior problems)
General / Constitutional (Fever, weight loss / gain, other)
Blood diseases (Bleeding disorders, sickle cell, other)
Other conditions not noted above:
Is there a family history of problems in the following areas? If so, please mark the relationship(s) to patient.
M=mother, F=father, S=sibling, GP=grandparent.
Myopia / Hyperopia as young child / infant
Other eye problems / diseases
High blood pressure / heart problems
Genetic or familial disorders
Other medical condition not listed above
Thank you for filling out your Children's History Form. If you would like to fill out paperwork for another child, you can return to this form after submitting.
I have filled out this form as accurately as possible and am complete. *