Medical History

1

Patient Name

First Name

Last Name

2

What brings you into the office?* This field is required.

Failed vision screening

Misalignment of the eyes

Double vision

Difficulty seeing

Eye redness or irritation

Other

3

Is there a history of glasses wear in the past* This field is required.

YESNO

4

Please specify for how long and how old are current glasses

5

Any history of patching?* This field is required.

YESNO

6

Please specify: when patching started, which eye, when patching discontinued

7

Any history of eye surgery* This field is required.

YESNO

8

Please specify: date of surgery, type of surgery and which eye

9

Any medical problems?* This field is required.

YESNO

10

Please specify

11

Current medications?* This field is required.

YESNO

12

Please list prescription and over the counter meds

13

Any allergies* This field is required.

YESNO

14

Please specify

15

Any problems with birth and delivery* This field is required.

YESNO

16

Any developmental delay?* This field is required.

YESNO

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