If you have an appointment scheduled, please enter date and time here.

First Name: 
Preferred nickname: 
Last Name: 
Address: 
City:  State:  Zip: 
Date Of Birth:  (mm/dd/yy)

Parent/Guardian:
Occupation: 

Telephone: Work:  Home: 

How did you find out about this program?
Friend / Family
Radio Ads
Print Ads
Website
Story in newspaper
Advertising on TV
Health Care Provider / Doctor
Name: 

Eye History
Have you ever noticed your any of the following happening with your baby's eyes?
(please check any that apply)
Baby's Eye(s):
Turn in
Turn out
Watering
Have swelling
White appearance in pupil

Explain any eye concerns noted by observing the child:

Developmental and Health History

Pregnancy

Length of pregnancy:
36 weeks or more
Less than 36 weeks
Uncomplicated
Mothers complications

Baby's complications

Delivery

Birth Weight
APGAR Score
Delivery complications? yes no
Oxygen used? yes no

List any delivery complications:

MEDICAL

Child’s Doctor:
Last Exam Date:
Are immunizations up to date? Yes No
Does your baby have any known food or drug allergies? No Yes:
List ALL medications taken regularly: None List:
List any complications of development:
Check all of the following that your baby can do at this time: Roll Over Sit Crawl Stand Walk
Has your baby ever had a high temperature (fever)? No Yes, how high?
Does your baby suffer from colic? No Yes, grade: mild moderate severe
Has your baby ever had tubes in the ears? Yes No

Please list any childhood illnesses your baby has had:
Illness 1:
Age at the time:
Was the illness? mild moderate severe

Illness 2:
Age at the time:
Was the illness? mild moderate severe

List any accidents, eye, or head injuries, and age they occurred:
Please list any other conditions we should know about:

Family History

Please list any family members with a history of eye or medical problems.

Regarding child’s caretakers:

Smoking: Yes No

Drinking alcohol: Yes No

Use of recreational drugs: Yes No

Please list anything else we should know about child health:

Thank you for carefully completing this confidential questionnaire. This information will allow for a more efficient use of examination time and will contribute to the understanding of infant eye and vision development.

By submitting this form you acknowledge the following statement:
I understand the above information is necessary to provide me with eye and vision care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge. With my approval, I authorize the Doctor to perform diagnostic procedures and treatments as may be necessary for proper eye and vision care. I understand my obligation for payment as described above.