Pediatric Ophthalmology and Strabismus
New Patient Health Questionnaire
Patient Name
*
First Name
Last Name
Today's Date
*
/
Month
/
Day
Year
Date
Patient Date of Birth
*
/
Month
/
Day
Year
Date
School
School Grade
Please list any specialists your child has seen. (i.e., neurologist, cardiologist, etc.)
Household/Family Status
Household Status
*
Patient living with biological parents or parent
Patient living with adoptive parents or parent
Patient living with relative, guardian or foster parent
Which parent?
Which parent?
Who?
Family Status: Parents are...
*
Married
Divorced
Never Married
Widowed
Separated
1. Name of sibling
Last Name
First Name
Date of Birth (sibling #1)
-
Month
-
Day
Year
Date
2. Name of sibling
Last Name
First Name
Date of Birth (sibling #2)
-
Month
-
Day
Year
Date
Have we seen any siblings as patients?
Yes
No
Birth History
Birthweight
*
lbs
oz
Problems during pregnancy?
*
Yes
No
If yes, please specify
Smoking
Alcohol
Drug Use
Other
Problems during delivery or forceps delivery?
*
Yes
No
Provide Details
Cesarean section
*
Yes
No
Provide details
Delivered more than two weeks early?
*
Yes
No
If early, age at birth in weeks
Baby kept in hospital due to illness?
*
Yes
No
Provide details
If in neonatal ICU, how many days?
Ventilator for breathing, how many days?
Delayed development?
*
Yes
No
What is the developmental age?
Family History
Are both parents alive and in good health?
*
Please Select
Yes
No
If no, explain
Have any of the patient’s relatives had any of the following?
Blindness
*
Yes
No
Who? Give details.
Patching for Amblyopia (lazy eye)
*
Yes
No
Who? Give details.
Strabismus (crossed or wandering eye)
*
Yes
No
Who? Give details.
Eye muscle surgery
*
Yes
No
Who? Give details.
Glasses before age 6
*
Yes
No
Who? Give details.
Cataracts in childhood
*
Yes
No
Who? Give details.
Glaucoma in childhood
*
Yes
No
Who? Give details.
Other serious eye disease
*
Yes
No
Who? Give details.
Deafness in childhood
*
Yes
No
Who? Give details.
Complications from anesthesia
*
Yes
No
Who? Give details.
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History of Eye Problems
Has the patient had any of the following?
Strabismus (crossed or wandering eye)
*
Yes
No
Give age when problem occurred and details.
Glasses
*
Yes
No
Give age when problem occurred and details.
Patching/Amblyopia
*
Yes
No
Give age when problem occurred and details.
Eye Surgery
*
Yes
No
Give age when problem occurred and details.
Eye Injury
*
Yes
No
Give age when problem occurred and details.
Other Eye Problems
*
Yes
No
Give age when problem occurred and details.
Recent Symptoms
Crossed or wandering eye
*
Yes
No
How long? Give details.
Excessive squinting
*
Yes
No
How long? Give details.
Excessive eye rubbing
*
Yes
No
How long? Give details.
Frequent tearing or discharge
*
Yes
No
How long? Give details.
Light sensitivity
*
Yes
No
How long? Give details.
Droopy eye lid
*
Yes
No
How long? Give details.
Clumsiness or bumping into things
*
Yes
No
How long? Give details.
Can’t make normal eye contact
*
Yes
No
How long? Give details.
Difference in pupils or irregular shape of pupil
*
Yes
No
How long? Give details.
Double vision
*
Yes
No
How long? Give details.
Blurred vision
*
Yes
No
How long? Give details.
Frequent headaches
*
Yes
No
How long? Give details.
Tired eyes when reading
*
Yes
No
How long? Give details.
Change in school performance
*
Yes
No
How long? Give details.
Other symptoms not mentioned
*
Yes
No
How long? Give details.
Other Medical Problems
(Medical History and Review of Systems)
Has the patient had any of the following?
Fever or weight loss
*
Yes
No
Give details:
Frequent ear infections
*
Yes
No
Give details:
Other ear, nose throat problems
*
Yes
No
Give details:
Heart problems or high blood pressure
*
Yes
No
Give details:
Lung disease
*
Yes
No
Give details:
Kidney or urinary disease
*
Yes
No
Give details:
Arthritis
*
Yes
No
Give details:
Other bone, joint, or muscle problems
*
Yes
No
Give details:
Diabetes, thyroid, or pituitary gland problems
*
Yes
No
Give details:
Stomach, digestion or intestine problems
*
Yes
No
Give details:
Skin rash, tumors or birthmarks
*
Yes
No
Give details:
Neurologic problems
*
Yes
No
Give details:
Seizure disorder
*
Yes
No
Give details:
Mental illness
*
Yes
No
Give details:
Sickle cell or other blood disease
*
Yes
No
Give details:
Cancer
*
Yes
No
Give details:
Medication allergies
*
Yes
No
Give details:
Other allergies
*
Yes
No
Give details:
Developmental delay
*
Yes
No
Give details:
Missing immunizations
*
Yes
No
Give details:
Airway concerns or anesthesia risk
*
Yes
No
Give details:
List any diagnosed syndromes or genetic disorders
*
List any previous surgery, hospitalizations, major illness, or injuries
*
List any medications the patient is taking, other than eye drops
*
List any eye drops the patient is taking
*
Does the patient smoke, drink alcohol or use illicit drugs?
*
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