New Patient Form

Demographics

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

Address:
City:		State/ZipCode	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 TX

Home Phone:		Work Phone:
Other Phone:		Alerts:
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. Lewis, Scott	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	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 TX

Home Phone:
Work Phone:

Medical History

Child's Full Name:

Child's 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 afraid of Doctors? Yes No Last Visit Date: For What Reason? Is your child generally healthy? Medications (including vitamins & supplements): Allergies to Medications: List Significant Illnesses, bad falls, high fevers or chronic Illnesses: Event/Condition...Age...Severity...Complications Event/Conditions...Age...Severity...Complications Neuro/Psych Eval? Yes No By Whom? Occupational Therapy Eval? Yes No By Whom? Poor Vision? Child Family If Family, who? Strabismus (Eyeturn) Child Family If Family, who? Amblyopia Child Family If Family, who? Cancer Child Family If Family, who? Epilepsy/Seizures Child Family If Family, who? Learning Issue Child Family If Family, who? Blindness Child Family If Family, who? Other 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 excessivley YesNo Reddened or encrusted eyelids YesNo Eyelid Droops YesNo Poor tracking / eye movements YesNo Head tilt / Face turn YesNo Stumbles over objects / Clumsy YesNo Poor motor control YesNo Medical History / System Review Does your child have or has your child had? Eye Injury of Surgery Yes No Lazy eye / Amblyopia Yes No Patching Yes No Vision Therapy / Orthoptics Yes No Surgery / Hospitalizations YesNo Breathing Problems YesNo Gastrointestinal Problems YesNo Musculoskeletal problems YesNo Neurological problems YesNo Developmental delay YesNo Ear / Nose / Throat problems YesNo Head Injury / Trauma YesNo Your Child's Developmental History 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 trauma use of alcohol injury by fall smoking use of drugs severe illness prescription medication little obstetrical care other Child's birthweight: Apgar score: after 10 minutes Please explain: My Child is: biological adopted foster other Please rate your child on the following skills/Milestones: Gross Motor Development Rolled Over? Average Child: 3.5 Months, Your Child Early Late Normal Unsure Sits w/out support? Average Child: 6.5 months, Your Child Early Late Normal Unsure

Walks unaided / Alone? Average Child: 12 months, Your child Early Late Normal Unsure

Kicks a ball? Average Child: 18 Months, Your child Early Late Normal Unsure

Toilet trained? Average Child 24 months, Your child Early Late Normal Unsure

Rides tricycle? Average Child 3 years, Your child Early Late Normal Unsure

Fine Motor Development:

Reaches/Grasp for object? Average Child 4 months, Your Child Early Late Normal Unsure

Scribbles spontaneously? Average Child 15 months, Your Child Early Late Normal Unsure

Stacks / piles blocks? Average Child 18 months, Your Child Early Late Normal Unsure

Eats with a fork/spoon? Average Child 3 years, Your Child Early Late Normal Unsure

Language Development:

Smiles spontaneously? Average Child 1 month, Your Child Early Late Normal Unsure

Says single words? Average Child 12 months, Your child Early Late Normal Unsure

Refers to self by first name? Average Child 18 months, Your Child Early Late Normal Unsure

Knows full name? Average Child 3 years, Your Child Early Late Normal Unsure

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?

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

EducationalYesNo

NeurologicalYesNo

PsychologicalYesNo

OccupationalYesNo

Speech/AuditoryYesNo

PhysicalYes No

If yes, please list all previous evaluations done on your child:

Main reason for having an examination today: Date of last visual 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?

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

Headaches YesNo

Blurred Vision Yes No

Double Vision Yes No

Eyes "Hurt" or "Tired" Yes No

Nausea when doing visual tasks Yes No

Motion sickness / car sickness Yes No

Bothered by light / sun light Yes No

Frequent styes Yes No

Eyes Itch YesNo

Eyes Burn Yes No

Eyes Tear Yes No

Eyes frequently reddened Yes No

Closing or covering one eye Yes No

Loses place when reading Yes No

Poor reading Comprehension Yes No

When reading, letters/words appear to move or float around YesNo

Loses attention easily Yes No Are there any other complaints your child makes concerning vision?

Do you have any other concerns / observations concerning your child's vision?

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?

Give a brief description of your child as a person

Reviewed by Scott R. Lewis, O.D., FCOVD

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