Southwest Family Eye Health Center, PLLC

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Loy, Jeremy	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None Blue Cross Blue Shield of Texas Medicare United Healthcare Enterprises
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None Blue Cross Blue Shield of Texas Medicare United Healthcare Enterprises
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None Blue Cross Blue Shield of Texas Medicare United Healthcare Enterprises
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Referred By:

Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Referring Doctor:

Family Patients:

Hobbies:

Interested In Contact Lenses?

Yes No

Ever Worn Contact Lenses?

Yes No

Type of CLs worn in past:

Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics

Back up specs for cls?

Yes No

Primary Vision Correction:

Bifocals Contacts Contacts - Mono None Progressives Single Vision Trifocals

Sunspecs?

Yes No

Interested in Laser Vision Correction?

Not Interested Yes

Primary Care Physician:

Eye Hx: Sting, Burn, Itch, Surgery, Injury, Cataracts, Lazy eye, Floaters, Glaucoma, Macular degeneration

Eye Meds:

Acular Artificial Tears Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Neosporin None Ocupress Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Timoptic .25% Timoptic .5% Tobradex Voltaren Xalatan None

Last Eye Doctor:

Primary Care Physician:

Systemic Meds:

Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+

Family Med History:

Artheritis Cancer Diabetes I Diabetes II Hypertension Hypercholesterolmia Heart Dx None Known None

Family Eye History:

Amblyopia Cataracts Glaucoma Macular Degeneration Retinal Detachment Weak Eye Lazy Eye None

Medication and Seasonal Allergies:

Erythromycin Iodine Pollen PCN Sulfa Codeine Tetanus NKDA None

NOTES/SOCIAL HISTORY

Pediatric History Form

Child's Full Name: Preferred Name:
Mother/Caretaker's Name:
Occupation: Bus. Phone:
Father/Caretaker's Name:
Occupation: Bus. Phone:

Your Child's Medical History

Pediatrician's Name: Is your child especially afraid of Doctors? Yes No
Last Visit Date: For What Reason? Is your child generally healthy?

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Medications (including vitamins & supplements):

Medication Allergies:

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List significant illnesses, bad falls, high fevers or chronic illnesses (asthma, allergies, frequent colds, ear infections)
Please include: Event/Condition, Age, Severity, and Describe any complications

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Has a neurological/psychological evaluation been performed? Yes No By Whom?
Has an occupational therapy evaluation been performed? Yes No By Whom?

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

Child Family If Family, Who? Poor Vision/Rx Strabismus Amblyopia Cancer

Child Family If Family, Who? Epilepsy/Seizures Learning Issue Blindness Other

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Do you notice or has your child complained of any of the following.

Eye turns in/out	Yes No
Squints/blinks a lot	Yes No
Covers/closes one eye	Yes No
Lacks interest in looking at objects	Yes No
Rubs eyes excessively	Yes No
Reddened or encrusted eyelids	Yes No
Eyelid Droops	Yes No
Poor tracking/eye movements	Yes No
Head tilt/Face turn	Yes No
Stumbles over objects or is clumsy	Yes No
Poor motor control	Yes No

Medical History/System Review

Does your child have or has your child had any of the following?

Any eye injury or surgery	Yes No
Any lazy eye/amblyopia	Yes No
Any patching	Yes No
Any vision therapy/orthoptics	Yes No
Surgery/hospitalizations	Yes No
Breathing problems	Yes No
Gastrointestinal problems	Yes No
Musculoskeletal problems	Yes No
Neurological problems	Yes No
Development delayed	Yes No
Ear/nose/throat problems	Yes No
Head Injury/ Trauma	Yes No

Your Child's Developmental History: (Please explain)

Length of Pregnancy: 30 weeks 31 weeks 32 weeks 33 weeks 34 weeks 35 weeks 36 weeks 37 weeks 38 weeks 39 weeks 40 weeks 41 weeks Type of delivery: Natural Caesarian Forceps / Vacuum Anesthesia
During pregnancy of this child, did any of the following occur:

toxemia	injury by fall	severe illness	other
trauma	smoking	prescription medication
use of alcohol	use of drugs	little obstetrical care
Please explain:

Child's birth weight: lbs. and ozs.
Apgar score @ birth after 10 min

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My child is: biological adopted foster other

Skills/milestones

Please rate your child on the following skills/milestones:

ACTIVITY	AVERAGE AGE	YOUR CHILD
Gross Motor Development
Rolled over	3.5 Months	Early Late Normal Unsure
Sits w/o support	6.5 Months	Early Late Normal Unsure
Walks unaided/alone	12 Months	Early Late Normal Unsure
Kicks a ball	18 Months	Early Late Normal Unsure
Toilet Trained	24 Months	Early Late Normal Unsure
Reaches/Grasp for object	4 Months	Early Late Normal Unsure
Scribbles spontaneously	15 Months	Early Late Normal Unsure
Stacks/Piles blocks	18 Months	Early Late Normal Unsure
Eats with a fork/spoon	3 Years	Early Late Normal Unsure
Language Development
ACTIVITY	AVERAGE AGE	YOUR CHILD
Smiles spontaneously	1 Month	Early Late Normal Unsure
Says single words	12 Months	Early Late Normal Unsure
Refers to self by first name	18 Months	Early Late Normal Unsure
Knows full name	3 Years	Early Late Normal Unsure

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How is your child performing compared to others his/her age: Above average Average Below average
How well developed is your child's spoken vocabulary?

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Has your child undergone any of the following testing/treatment/therapy?

Educational	Yes No	Neurological	Yes No	Psychological	Yes No
Occupational	Yes No	Speech/Auditory	Yes No	Physical	Yes No

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Visual History

Main reason for having an examination today:

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Date of last evaluation: Doctor's name:
Reason for examination:
Results/recommendations:
Were glasses, contact lenses or other optical devices recommended? Yes No
If yes, are they used? Yes No Sometimes If yes, when?
If no, why not?

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Do you observe or does your child report any of the following:

	Yes	No
Headaches
Blurred vision
Double vision
Eyes "hurt" or "tired"
Nausea when doing visual tasks
Motion sickness / car sickness
Bothered by light / sun light
Frequent styes
Eyes itch
Eyes burn
Eyes tear
Eyes frequently reddened
Closing or covering one eye
Loses place while reading
Poor reading comprehension
When reading, letters/words appear to move or float around
Loses attention easily

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Are there any other complaints your child makes concerning vision?
Do you have any other concerns/observations concerning your child's vision?

Referral Information

Were you referred to our office? Yes No Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?

Submit Data