Child History
-----SECTION 1------PEDIATRIC EYE HEALTH HISTORY------PLEASE COMPLETE FOR YOUR CHILD------------------------------------------------------------------
______________________________________________________________________________________________________________________________________________________
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?
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?
______________________________________________________________________________________________________________________________________________________
Other:
______________________________________________________________________________________________________________________________________________________
MED HX / SYSTEM REVIEW:
*** If yes, please complete Strabismus/Amblyopia section under the Additional Info tab.
______________________________________________________________________________________________________________________________________________________
DEVELOPMENTAL HISTORY:
Length of Pregnancy:
Type of delivery:
Forceps / Vacuum
Anesthesia
During pregnancy of this child, did any of the following occur:
Child's birthweight:
lbs. and oz.
Apgar score:
@ birth
after 10 minutes
My child is:
biological
adopted At what age?
foster
other Explain:
______________________________________________________________________________________________________________________________________________________
SKILLS / MILESTONES:
| GROSS MOTOR |
| ACTIVITY |
AVERAGE AGE |
YOUR CHILD |
| Rolled over |
3.5 months |
|
| Sits w/out support |
6.5 months |
|
| Walks unaided / alone |
12 months |
|
| Kicks a ball |
18 months |
|
| Toilet trained |
24 months |
|
| Rides tricycle |
3 years |
|
| FINE MOTOR |
| ACTIVITY |
AVERAGE AGE |
YOUR CHILD |
| Reaches / grasp for object |
4 months |
|
| Scribbles spontaneously |
15 months |
|
| Stacks / Piles blocks |
18 months |
|
| Eats with a fork/spoon |
3 years |
|
| LANGUAGE |
| ACTIVITY |
AVERAGE AGE |
YOUR CHILD |
| Smiles spontaneously |
1 month |
|
| Says single words |
12 months |
|
| Refers to self by first name |
18 months |
|
| Knows full name |
3 years |
|
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?
If yes, please list all previous evaluations done on your child:
Current grade in school:
School:
What is their favorite subject?
______________________________________________________________________________________________________________________________________________________
VISUAL HISTORY:
Main reason for having an examination today:
Date of last evaluation:
Doctor's name:
Pharmacy:
Reason for examination:
Were glasses, contact lenses or other optical devices recommended?
If yes, are they used?
If yes, when?
If no, why not?
Results / Recommendations:
Do you observe or does your child report any of the following?
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:
Phone:
If not referred, how did you hear about us?
----- SECTION 6 ------ READING AND COMPUTER SYMPTOM CHECKLIST ----------------------------------------------------------------------------------------
CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)
Please answer the following questions about how your eyes feel when reading or doing close work.
NOTE: If the patient is a child, please read the instructions and then each item exactly as written.
If the patient responds with "yes" please qualify with frequency choices. Do not give examples.
Points: Never =0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4
NOTE: For children a score of 16 or more indicates the need for a binocular vision evaluation. For adults a score of 21 does.
In addition:
Check all that apply:
Adult History
-----SECTION 3--------ADULT EYE HEALTH HISTORY -------------------------------------------------------------------------------------------------------
When was your last eye exam:
Where:
Who is your Primary Care Physician:
Pharmacy:
Do you have any MEDICATION ALLERGIES?
Please list all MEDICATIONS you currently use (including over the counter, eye drops and supplements):
List all EYE SURGERIES or INJURIES:
Have you been diagnosed with any of the following EYE CONDITIONS (check all that apply)?
Other Eye Conditions:
Check any of the following symptoms you experience:
Eye Strain with Reading or Computer Work
If yes, complete reading/computer tab
Dizziness or Car Sickness
If yes, complete dizziness/motion sensitivity tab.
Other Eye Symptoms:
VISION HISTORY
What is your primary Vision Correction?
Have you ever worn Contact Lenses?
Are you interested in Contact Lenses?
Are you interested in Laser Vision Correction?
If yes, please bring your current prescription information with you
Are your Contact Lenses comfortable and working well for you?
Do you have additional glasses? (back up, reading, computer, sun, music, etc)
What is your primary occupation?
How many hours per day do you work on a computer?
List your hobbies or other activities:
CURRENT GENERAL HEALTH HISTORY
Do any of the following conditions apply to you?
Currently Pregnant
List any other conditions (such as Autism, Down Syndrome, ADD/ADHD, Hearing impaired, Speech impaired, Anxiety disorder etc...)
Do you use any of the following:
Alcohol
Tobacco
Recreational Drugs
FAMILY HISTORY
Is there a history of any of the following conditions in your immediate family?
Other Family History of Eye Conditions:
______________________________________________________________________________________________________________________________________________________
Were you referred to our office?
Whom may we thank for this referral?
Referral address:
Phone:
If not referred, how did you hear about us?
Additional Info
-----SECTION 2-----STRABISMUS / AMBLYOPIA HISTORY ----------------------------------------------------------------------------------------------------
(for children and adults with a lazy eye, eye turn or crossed or wandering eye)
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)?
Up
Down
Out
In
Which eye turns?
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:
Do you ever notice one or both eyes shaking rapidly?
If patching treatment was prescribed, please describe at what age patching was started,
how it was done, the eye patched, for how long, and an estimate of the results.
Has there been any surgery?
If yes, estimate the results:
Please describe any visual therapy, including duration of treatment, age at which it was started and estimate the results:
-----SECTION 4--------BRAIN INJURY -------------------------------------------------------------------------------------------------------------------
(Stroke, Head injury, Concussion, Whiplash, Motor Vehicle Accident, Bike Accident, Brain Surgery, etc...)
Date of most recent event:
Briefly describe the injury:
What part of the head was affected:
Face
Top of head
Back of head
Left side
Right side
Forehead
Was there loss of consciousness? For how long?
When did you first see a doctor regarding your accident/injury?
Where you hospitalized?
Describe any previous injuries and dates:
WHAT TYPES OF PROFESSIONAL CARE HAVE YOU RECEIVED OR ARE RECEIVING DUE TO THIS INJURY?
(List care such as neurological, psychological, occupational therapy, physical therapy, speech, auditory, chiro, osteopathic, acupuncture, neurofeedback)
What is your most significant visual concern at this time?
####### B I V S S ######### (Brain Injury Vision Symptom Survey) #############################################################
Score each behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4
EYESIGHT CLARITY
VISUAL COMFORT
DOUBLING
LIGHT SENSITIVITY
DRY EYES
DEPTH PERCEPTION
PERIPHERAL VISION
READING
If you experience any of the symptoms below, please check if the symptom was present before the injury, only after or both.
What activities can you no longer engage in due to your accident / injury?
----- SECTION 5 ------ DRY EYE HISTORY ---------------------------------------------------------------------------------------------------------------
Over the past week, which of the following eye symptoms have you experienced?
Do you take Omega-3 supplements daily?
Do you use Visine or other "get the red out" drops?
How often?
Have you ever been prescribed RESTASIS eye drops?
----- SECTION 7 ----- DIZZINESS AND MOTION SENSITIVITY CHECKLIST -------------------------------------------------------------------------------------
(Dizziness, Motion Sickness, Car Sickness, etc)
Check all of the symptoms that are significant for you:
Nausea, headache or dizziness when reading in the car even on a STRAIGHT road
Nausea, headache or dizziness when sitting close to a movie screen or watching a train go by
Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days)
Frequent, sometimes daily, headache or "pressure" in your head
Nausea, headache, dizziness or spacey feeling when shopping or moving through crowds of people
Unusual fear of heights
Lose your place easily when reading
Flickering lights bother you (light through trees when driving or fluorescents)
Avoidance of driving because of car sickness
Policies, Consent and Submit Data
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.THE
PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this
Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy
practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we
replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted
by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health
information that we maintain, including health information we created or received before we made the changes. In the event we make a
material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time.
For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the
end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment
to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation
between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d)
recall information.
Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing
and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its
responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage,
adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities;
and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare
operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or
credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us
written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in
effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in
this Notice.
Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written
authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will
never sell your health information without your prior authorization.
To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this
Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your
healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in
our professional judgment.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or
locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition,
or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an
opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health
information based on a determination using our professional judgment disclosing only health information that is directly relevant to the
person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make
reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms
of health information.
Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and
administrative proceedings.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim
of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances.
We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health
information of inmate or patient under certain circumstances.
Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and
services that may be of interest to you.
PATIENT RIGHTS
Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide
copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request
in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the
end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access
by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for
providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a
fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health
information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other
activities, for the last 6 years, but not for disclosure made prior to April14, 2003. If you request this accounting more than once in a
12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are
not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request in writing that we communicate with you about your health information by
alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation
how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why
the information should be amended. We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in
written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may
have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request
you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means
or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a
written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with
the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will
not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Dr. Ilana Gelfond-Polnariev
Telephone: 718-481-2020
Address: 4300 Hylan Blvd, Suite 1BC, Staten Island, NY 10312
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