Hartland Eye Care - Optometrist In Hartland, MI USA

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Child History Form

First Name *

Last Name *

Address *

City

State

Zip Code

Parents Work Phone

Home Phone *

Date of Birth

Father's Name

Mother's Name

Current Grade

Date of Last Eye Exam

Primary Vision Insurance

Secondary Vision Insurance

Primary Medical Insurance

How did you hear about our office (check all that apply?

Prior Patient Friend Referral (write name below) Doctor Referral (write name below) Yellow Pages Web Page Saw Sign / Building Insurance Listing Other (describe below0

Please share information about your referral here.

Medical History

Have you had any of the following medical problems?

Gastrointestinal

Ear / Nose / Throat

Cardiovascular

Respiratory

High Blood Pressure

Neurological

Urinary

Muscles / Bones / Joints

Skin

Eyes

Endocrine

Blood / Lymph

Allergic / Immunological

Headaches

Mental / Anxiety

List your medications and what they are for (ex. Insulin / Diabetes):

Are you allergic to any medications?

List any medications you are allergic to:

Name of Pediatrician:

Date of last exam:

List any surgeries:

Family History

Have any of your immediate family members had any of the following conditions?

Glaucoma

Diabetes

Macular Degeneration

Retinal Detachment

Personal History

What is the main reason for your visit today?

How well is your child (the patient) doing in school?

Please check all that apply to patient:

Spends a long time doing homework Reduced attention span Covers one eye at times Lays head on desk when doing near work Frequently loses place when reading Skips or re-reads words and lines Reverses words or letters (was for saw, b for d) beyond second grade Does better at math than English, History or Social Studies Must re-read material several times to grasp its meaning Gets tired quickly when doing reading or homework Short attention span Daydreams a lot Learns best through auditory tactics (listens to learn) Misbehavior has become a problem (acts up, class clown, moody or depressed about school, aggresive) Avoids work that includes reading or near seeing Is more than one year behind in reading skills Has poor posture, slouches or slumps in chair

List any sports you play regularly:

Is there anything we forgot to ask?

Please tell us anything you think would help us serve you better during your exam:

Enter the verification code in the box below.

Verification Code: *

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Child History Form

Medical History

Have you had any of the following medical problems?

Family History

Personal History

Is there anything we forgot to ask?

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