If you are new to our office, please share with us how you found us.
Child's Grade Level: School:
Does your child...? (Check all that apply)
wear prescription glasses?
wear contact lenses? If so, what kind? Solution used:
have a rapidly increasing prescription
participate in sports?
Are you considering contact lenses for your child?
What specific concerns regarding your child's vision would you like to discuss with the doctor today?
How long has this problem/difficulty been observed?
Date of Last Eye Exam: Previous Eye Doctor:
In the past 6 months, has your child experienced any of the following? (Please check all that apply)
Other eye problems/issues:
Do you have a family history of any of the following? (Please check all that apply)
CURRENT MEDICATIONS (Please list ALL medications including eye drops and supplements)
Please list any ALLERGIES to medications (including topical medications):
Premature birth? Any complications during pregnancy? If yes, please describe:
Shown normal development? Had physical/developmental therapy?
Please list serious illnesses, bad falls, etc.:
Please list any surgeries, including eye surgeries.
Has your child ever been diagnosed or treated for any of the following health conditions? (Please check all that apply)
If your child has any other health conditions not listed above, please include those here:
Does your child use an Ipad/tablet in the classroom?
How much screen time does your child get per day?
Does your child have a 504 plan or I.E.P. at school?
Has your child had extra help or tutoring in school?
Has a grade been repeated?
If so, which?
How would you describe your child's reading ability?
Does he/she like to read for fun?
School/after-school activities your child is involved in:
Do you feel your child is achieving up to potential?
OPTIONAL Demographic Information: (This information if obtained for reporting purposes only)