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19
Questions
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1
Patient Name
First Name
Last Name
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2
What brings you into the office?
*
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Failed vision screening
Misalignment of the eyes
Double vision
Difficulty seeing
Eye redness or irritation
Other
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3
Is there a history of glasses wear in the past
*
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YES
NO
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4
Please specify for how long and how old are current glasses
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5
Any history of patching?
*
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YES
NO
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6
Please specify: when patching started, which eye, when patching discontinued
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7
Any history of eye surgery
*
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YES
NO
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8
Please specify: date of surgery, type of surgery and which eye
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9
Any medical problems?
*
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YES
NO
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10
Please specify
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11
Current medications?
*
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YES
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12
Please list prescription and over the counter meds
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13
Any allergies
*
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YES
NO
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14
Please specify
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15
Any problems with birth and delivery
*
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YES
NO
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16
Any developmental delay?
*
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YES
NO
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17
Schooling
*
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Not yet in school
On grade level or above
Below grade level
Has IEP
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18
Family history of eye problems
*
This field is required.
None
Misalignment of the eyes/ Strabismus
Amblyopia/ Lazy Eye
Glasses wear before age 5
Childhood Eye Surgery
Other
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19
Are there currently any problems in the following areas:
Yes
No
General/ Constitutional
Ear/Nose/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genital/ Kidney/ Bladder
Muscle/ Bones/ Joints
Skin
Neurologic
Psychiatric
Endocrine
Blood/ Lymph
Allergic/ Immunologic
General/ Constitutional
Ear/Nose/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genital/ Kidney/ Bladder
Muscle/ Bones/ Joints
Skin
Neurologic
Psychiatric
Endocrine
Blood/ Lymph
Allergic/ Immunologic
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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