New Patient Form


TitlePatient First NamePatient Last NameMISuffixNickname
City: State/ZipCode
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 Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?

Home Phone:
Work Phone:

Medical History

Child's Full Name:
Child's Preferred Name:
Mother/Caretaker's Name:
Bus. Phone:
Father/Caretaker's Name:
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:
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?
Child Family If Family, who?
Child Family If Family, who?
Child Family If Family, who?
Learning Issue
Child Family If Family, who?
Child Family If Family, who?
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:
Type of delivery:
Forceps / Vacuum Anesthesia
During Pregnancy of this child, did any of the following occur?
use of alcohol
injury by fall
use of drugs
severe illness
prescription medication
little obstetrical care
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
Sits w/out support? Average Child: 6.5 months, Your Child
Walks unaided / Alone? Average Child: 12 months, Your child
Kicks a ball? Average Child: 18 Months, Your child
Toilet trained? Average Child 24 months, Your child
Rides tricycle? Average Child 3 years, Your child
Fine Motor Development:
Reaches/Grasp for object? Average Child 4 months, Your Child
Scribbles spontaneously? Average Child 15 months, Your Child
Stacks / piles blocks? Average Child 18 months, Your Child
Eats with a fork/spoon? Average Child 3 years, Your Child
Language Development:
Smiles spontaneously? Average Child 1 month, Your Child
Says single words? Average Child 12 months, Your child
Refers to self by first name? Average Child 18 months, Your Child
Knows full name? Average Child 3 years, Your Child
How is your child performing compared to others his/her age:
How well developed is your child's spoken vocabulary?
Has your child undergone any of the following testing/treatment/therapy?
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?
If yes, are they used? 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?
Whom may we thank for this referral?
Referral address:
If not referred, how did you hear about us?
Give a brief description of your child as a person
Reviewed by
After Completing All Forms Submit Data on Final Tab