CHILD PATIENT HISTORY & REGISTRATION Name First Last DOB Date Format: MM slash DD slash YYYY GenderFemaleMaleNon-BinaryPreferred PronounSheHeTheyGrade LevelSchool NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Siblings of Patient (Name and ages)PARENT INFORMATIONLegal Parent/Guardian (I) NameDOB Date Format: MM slash DD slash YYYY Cell PhoneHome PhoneIs this the same for the patient?YesNoEmail Address EmployerOccupationWork PhoneIs this a good day time number?YesNoLegal Parent/Guardian (II) NameDOB Date Format: MM slash DD slash YYYY Cell PhoneHome PhoneIs this the same for the patient?YesNoEmail Address EmployerOccupationWork PhoneIs this a good day time number?YesNoMEDICAL HISTORYPediatrician NamePhoneDate of Last Checkup Date Format: MM slash DD slash YYYY Has the child ever been diagnosed or treated for the following? AIDS/HIV Allergies Anxiety Arthritis Asthma Brain Injury Cancer Cholesterol Concussion Diabetes Encephalitis Heart Disease Head Trauma High Blood Pressure High Fever Insomnia Kidney Measles Neurological Conditions Rheumatic Fever Serious Infections/Injuries Thyroid Conditions Other Please list the names of current medications (Rx and Over the Counter), including vitamins, eye drops, and birth control pillsPlease list any allergies to medications, if applicableplease list the conditions and relationship of relativeHas the child ever been hospitalized?YesNoplease provide detailsWas the child considered “difficult birth”?YesNoMilestonesNormalDelayedNot SureEYE HISTORYDate of Last Eye Exam Date Format: MM slash DD slash YYYY Purpose for Today’s VisitChild wears glasses for Computer Reading Tv School Other Child wears contacts for _ hours per dayBrandTypeHas the child ever been diagnosed or treated for the following? Autism Eye Infection Eye Injury Lazy Eye Reading/Learning Problems Does (child) have any blood relative with any of the previous conditions?YesNoplease list the conditions and relationship of relativeHow did you hear about us? Internet Advertisement Doctor Referral Other Child Visual Skills ChecklistPatient’s NameAgeDate Date Format: MM slash DD slash YYYY Parent’s Names:Parent (I)Parent (II)SymptomsPlease estimate how often the above-named exhibits the behaviors on this list.ALWAYSOFTENSOMETIMESNEVERComplains of headaches, uncomfortable, or blurred visionComprehension reduces as reading continuesSquints or blinks excessively at desk or while readingHolds reading material too closely, or holds face close to desk surfaceOmits/inserts small words/loses place when readingUses a finger to keep his/her place while readingConfuses minor differences in words when readingReverses letters or words in writing and copyingWrites crookedly, poorly spaced, or does not stay on ruled linesExperiences trouble copying from the boardExperiences clumsiness or coordination issuesSees double or covers 1 eyeExperiences eye crossing or wandersNot working up to academic potentialExhibits dizzess/balance problemsSignatureI UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES AT TIME OF SERVICEHealth Information Protection* I have read and agree to the Privacy Policy SIGNATURE OF RESPONSIBLE PARTYRELATIONSHIPDate Date Format: MM slash DD slash YYYY