Online Patient Form

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Patient Information
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/GuardianDrivers License #

Health History

Mother/Caretaker's Name: Father/Caretaker's Name:

Occupation: Bus. Phone: Occupation: Bus. Phone:

Child's Preferred Name: School: Grade: Referred By:

I Hereby Authorize The Following Persons To Vring My Minor Child To The Office For Treatment.

Name Relationship Name Relationship

I Hereby Authorize JVDC To Discuss Vision / Medical / Financial / Insurance Information For Myself Or My Minor Child With:

Name Relationship Name Relationship

Medical History

Retinal Detachment
Macular Degeneration
Diabetic Retinopathy
Problem Headache
High Blood Pressure
Blood Disorders
Gastrointestinal Problems
Heart Disease
Skin Disorder
Allergies / Hay Fever
Arthritis / Joint pain
Kidney Disease
Seizures / Epilepsy
Head Trauma

Family Medical History:

Pregnant? Alcohol use? Tobacco use?

Family Pysician/ Pediatrician Last physical exam

Ocular History

Strabismus (Eye Turn)
Eye Surgery
Eye Patching
Eye Injury
Flashes Of Light
Light Sensitivity
Eye pain
Watery Eyes
Itchy Eyes
Burning Eyes
Red Eyes
Chronic Eye Infections
Stye (Chalazion)
Blurred Vision
Loss Of Vision
Double Vision

Family Ocular History:

Date of Last Eye Exam by Dr.

Interrested in CL's? Were glasses or contact lenses prescribed at last exam? If yes, are they used?

Main reason for having an examination today:

Strabismus History ***Only Fill Out If Patient Has An Eye Turn***

At what age was the eye turn first noticed? Did it start suddenly or gradually?

Which Direction Does The Eye Turn (Check All That Apply)? In Out Up Down

Which Eye? Right Left Both

Is the eye turn getting worse, better or no change?

When does the eye turn (always, what % of time, when tired, when ill, etc)?

Does The Eye Turn More When Looking: up close in the distance to the left to the right up down

Do you ever notice one or both eyes shaking rapidly?

Developmental History

My Child Is: biological foster adopted

Was your child born premature? If yes, how may weeks? Birth weight

Any known complications at birth or first 3 months of life

Delays or difficulties with learning to speak? Delays or difficulties with learning to sit/ crawl/ walk?

Any Other Medical / Developmental Diagnoses (ex. Autism, ADHD, Learning Disability, Down's Syndrome)?

Is your child's school performance equal to his/her classmates?

Have You Noticed Any Of The Following Behaviors?

Holding Things Too Close
Head turning when reading
Squinting one or both eyes
Loses place when reading
Covering one eye
Frequent letter reversals
Poor eye-hand coordination
Poor reading comprehension