New Patient Form

Demographics

Please fill out the questionnaire below. If you are filling this out for a child, all questions refer to the child. If you do not know the answer to a question, feel free to leave it blank. Thank you!

TitleFirstLastMISuffixNickname
Address:
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?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History


Please fill out the questionnaire below. If you are filling this out for a child, all questions refer to the child. If you do not know the answer to a question, feel free to leave it blank. Thank you!

Full Name: Nick Name:
Date of Birth:  Age:    Male    Female
Please list the names and dates of birth for other family members:
Spouse (if applicable):    Date of Birth:
Mother/Guardian (if minor):    Date of Birth:
Father/Guardian (if minor):   Date of Birth:
Child/Sibling (if minor):    Date of Birth:
Child/Sibling (if minor):    Date of Birth:
Child/Sibling (if minor):    Date of Birth:
Child/Sibling (if minor):    Date of Birth:

Were you referred to our office? Yes   No  
Whom may we thank for this referral?
If not referred, how did you hear about us?

VISUAL HISTORY:
Main reason for having an examination today:
Date of last evaluation:   Doctor's name:
Results / Recommendations:
Check all that apply.
I currently wear: Glasses Part-time Full-time   
If part-time, how often/when?
Contact Lenses Soft Rigid Gas Permeable Part-time Full-time  
If part-time, how often/when?
Contact Lens Wearers:
Are your lenses comfortable? Yes No   Current Brand:
What solution do you use?   
What is your replacement schedule?   How old is your current pair?
Do you use any eyedrops (Rx or OTC)? Yes No   
If yes, please list name/how often used:

Do you have a history of any of the following?
YES NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Patching
Vision Therapy
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Other Eye Disease

If yes, what disease?

List any eye surgeries:

Describe any eye injuries:

Do you use a computer? Yes No
If yes, how many hours a day?
Any visual symptoms after using the computer?    Yes No
If yes, describe those symptoms:
  Do you experience any of the following?
YES NO
Headaches
Blurred Vision
Double Vision
Closing or covering one eye
Eyes "hurt" or "tired"
Nausea when doing visual tasks
Motion sickness / car sickness
Halos around lights
Bothered by light / sun light
Frequent blinking
Frequent styes
Eyes frequently reddened
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashes
Floaters





SYMPTOMS CHECKLIST:

Do you experience any of the following?

YES NO
Head close to paper when reading/writing
Avoid reading
Prefer being read to
Lose place while reading
When reading, letters/words
             appear to move or float around
Tilt head when reading/writing
Move head when reading
Skip, reread or omit words
Vocalize when reading silently
Read slowly
Use finger as a marker
Poor reading comprehension
Write or print poorly
Write neatly but slowly
Awkward or immature pencil grip
Frequent erasures

Please describe any other visual symptoms not described above:
 


YES NO
Confuse letters or words
Reverse letters or words
Confuse right and left
Tire easily
Lose attention easily
Difficulty copying from board
Difficulty recognizing same word
             on different page
Difficulty with memory
Remember better hearing than seeing
Respond better orally than by writing
Know material, but do poorly on tests
Dislike/avoid near tasks
Poor large motor coordination
Poor fine motor coordination
Difficulty with scissors/small hand tools
Dislike/avoid sports
Difficulty catching/hitting a ball




MEDICAL HISTORY / REVIEW OF SYSTEMS:

Physician's Name:
Last Visit Date: For What Reason?
List all medications you are currently taking and dosages (including any OTC/vitamins):

Do you have any allergies to medications? Yes No
If yes, please list:
Ladies, are you pregnant or nursing? N/A Yes No
If yes, what is the due/birth date?
List significant illnesses, high fevers, injuries, or hospitalizations, including date and any complications:

Has a neurological evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:
Has a psychological evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:
Has an occupational therapy evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:

>
Do you have, or ever had, any CHRONIC problems in the following areas?
  YES NO     YES NO
Neurological Cardiovascular
   Migraines    High blood pressure
   Seizures    Stroke
   Multiple Sclerosis Gastrointestinal
      Genitourinary
Endocrine Musculoskeletal
   Diabetes    Arthritis
   Thyroid problems Skin problems
      Lymphatic/Hematological
Ear/Nose/Throat    Anemia
   Allergies/Hay fever Cancer
   Ear infections Psychiatric disorder
   Dry throat/mouth Developmental delay
      ADD/ADHD
Breathing problems Other
   Asthma      
   Emphysema      

If you checked YES to any of the above, please explain:



FAMILY HISTORY

Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?

  YES NO Relationship to Patient   YES NO Relationship to Patient
Poor vision Cancer
Blindness Diabetes
Eye turn (Strabismus) High Blood Pressure
Lazy Eye (Amblyopia) Stroke
Glaucoma Thyroid Disease
Cataracts Other Inherited Disease
Macular Degeneration If yes, what disease?    
Retinal Detachment/Disease        


SOCIAL HISTORY
You may discuss this portion directly with the doctor if you prefer. If so, check here:

  YES NO  
Do you use tobacco products? If yes, type/amount/how often:
Do you drink alcohol? If yes, type/amount/how often:
Do you use illegal drugs? If yes, type/amount/how often:


Are you currently or have you ever been infected with:
  YES NO  
Tuberculosis
Hepatitis
HIV
Syphilis
Chlamydia

The following sections are for our pediatric patients only. Adult patients may skip the remaining sections.

DEVELOPMENTAL HISTORY:


Length of Pregnancy: Type of delivery: Forceps / Vacuum used

During pregnancy of this child, did any of the following occur:
toxemia smoking
severe illness use of alcohol
trauma use of drugs
other  
Please explain:
Child's birthweight: lbs. and ozs.
Apgar score: @ birth after 10 minutes

Please list all immunizations child has received and date:


Any reactions to immunizations? Yes No
If yes, please explain:


Was there ever any concern over your child's general growth or development? Yes No
If yes, why?


Did your child crawl (stomach on floor)? Yes No
If yes, at what age?

Did your child creep (on all fours)? Yes No
If yes, at what age?

At what age did your child walk? Was child active? Yes No

Speech: First words:

At what age?
Was early speech clear to others? Yes No
Is speech clear now? Yes No


SCHOOL:

Name of school:
Grade:
Teacher:

Address of school:

Age at time of entrance to:
Pre-school: Kindergarten: First Grade:

Does your child like school? Yes No

Specifically describe any school difficulties:


Has your child changed schools often? Yes No
If yes, when and why?


Has a grade been repeated? Yes No
If yes, which and why?


Does your child seem to be under tension or pressure when doing school work? Yes No
Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No

If yes, when and how long?
Where and from whom?

Results:


Does your child like to read? Yes No
Does your child read for pleasure? Yes No
Overall schoolwork is: Above average Average Below average

Which subjects are:
Above average:

Average:

Below average:


Does your child spend a lot of time/effort to maintain this level of performance? Yes No
How much time does your child spend each day on homework?

To what extent do you assist your child with homework?


Do you feel your child is achieving up to potential? Yes No
Does the teacher feel your child is achieving up to potential? Yes No



GENERAL BEHAVIOR:

Are there any behavior problems at school? Yes No
If yes, what?


Are there any behavior problems at home? Yes No
If yes, what?


What is your child's reaction to fatigue? Sag Irritable Other


What is your child's reaction to tension? Avoidance Irritable Other


Does your child say and/or do things impulsively? Yes No
Can your child sit still for long periods? Yes No
Is your child in constant motion? Yes No


Please give a brief description of your child as a person:


Is there any other information you feel would be helpful/important in our treatment of your child?


Submit

Thank you for taking the time to fill out our online History Questionnaire form.
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Please be sure you have filled out both the demographics tab AND the medical history tab before clicking submit.
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