Medical History - Child

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19Questions

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
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
Huge
Large
Normal
Small
Ok
Ok
5
Any history of patching?* This field is required.
YESNO
6
Please specify: when patching started, which eye, when patching discontinued
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Large
Normal
Small
Ok
Ok
7
Any history of eye surgery* This field is required.
YESNO
8
Please specify: date of surgery, type of surgery and which eye
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Large
Normal
Small
Ok
Ok
9
Any medical problems?* This field is required.
YESNO
10
Please specify
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Large
Normal
Small
Ok
Ok
11
Current medications?* This field is required.
YESNO
12
Please list prescription and over the counter meds
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Large
Normal
Small
Ok
Ok
13
Any allergies* This field is required.
YESNO
14
Please specify
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Large
Normal
Small
Ok
Ok
15
Any problems with birth and delivery* This field is required.
YESNO
16
Any developmental delay?* This field is required.
YESNO
17
Schooling* This field is required.
Not yet in school
On grade level or above
Below grade level
Has IEP
Other
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
19
Are there currently any problems in the following areas:* This field is required.
Yes
No
General/ Constitutional
Row 0, Column 0
Row 0, Column 1
Ear/Nose/Throat
Row 1, Column 0
Row 1, Column 1
Cardiovascular
Row 2, Column 0
Row 2, Column 1
Respiratory
Row 3, Column 0
Row 3, Column 1
Gastrointestinal
Row 4, Column 0
Row 4, Column 1
Genital/ Kidney/ Bladder
Row 5, Column 0
Row 5, Column 1
Muscle/ Bones/ Joints
Row 6, Column 0
Row 6, Column 1
Skin
Row 7, Column 0
Row 7, Column 1
Neurologic
Row 8, Column 0
Row 8, Column 1
Psychiatric
Row 9, Column 0
Row 9, Column 1
Endocrine
Row 10, Column 0
Row 10, Column 1
Blood/ Lymph
Row 11, Column 0
Row 11, Column 1
Allergic/ Immunologic
Row 12, Column 0
Row 12, Column 1
General/ Constitutional
Ear/Nose/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genital/ Kidney/ Bladder
Muscle/ Bones/ Joints
Skin
Neurologic
Psychiatric
Endocrine
Blood/ Lymph
Allergic/ Immunologic
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
Yes
Row 8, Column 0
No
Row 8, Column 1
Yes
Row 9, Column 0
No
Row 9, Column 1
Yes
Row 10, Column 0
No
Row 10, Column 1
Yes
Row 11, Column 0
No
Row 11, Column 1
Yes
Row 12, Column 0
No
Row 12, Column 1
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