School Age Child Patient Form Patient Form — School Age Child Date MM slash DD slash YYYY Patient Name: First Last M F DOB: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell #Preferred Contact Name & Number:E-Mail Address NicknameGrade LeveName of School:Parent/Legal Guardian 1Parent/Legal Guardian 2:List all siblings and their ages Add RemoveWere you referred to our office? Yes No Whom may we thank for referring you?Please fill out name, location, & contact information of the referral source.Address(es) of individual(s) who performed evaluation and/or treatmentName of professional who referred you:Address of professional who referred you: Street Address Address Line 2 City ZIP / Postal Code PhoneFAXEmail Do we have permission to communicate findings with referral source? Yes No how did you hear about us?MEDICAL HISTORY:Pediatrician's Name and NumberDate of last visit: MM slash DD slash YYYY Reason for last visit:Is your child especially afraid of doctors:Is your child generally healthy:List any medications your child currently takes (including vitamins and supplements) Add RemovePoor Vision: Child Family who?Strabismus(wandering/turned eye): Child Family who?Amblyopia(lazy eye): Child Family who?Cancer: Child Family who?Epilepsy/Seizures: Child Family who?Learning Issue: Child Family who?MEDICATION ALLERGIES: (Name of medication and reaction)List significant illnesses, bad falls, high fevers, or chronic illnesses Add RemoveVISUAL HISTORY:Main reason for today's examination:Date of last evaluation: MM slash DD slash YYYY Doctor's name:Reason for examination:Were glasses, contact lenses or other optical devices recommended? Yes No why not?Results/Recommendations:Visual Skills & Visual Processing: Does your child experience the following?Headaches Yes No What part of head:Headache after reading Yes No Blurry Vision Yes No Eyes hurt or tired when reading Yes No Double Vision Yes No Squints Yes No Blinks eyes excessively Yes No Has a droopy eyelid? Yes No Has a head tilt or a head turn Yes No Clumsy Yes No Poor eye/hand coordination Yes No Poor gross motor or fine motor skills Yes No Closes or covers an eye Yes No Reduced attention for reading Yes No Loss of place when reading Yes No Reads with head movement rather than with eye movement Yes No Loss of place when copying off the board Yes No Loss of place on Scantron Tests Yes No Omits words when reading Yes No Substitutes words when reading Yes No Adds words when reading Yes No Reverses letters or numbers, or transposes letters within words Yes No Confuses right and left Yes No Mixed hand dominance Yes No Skips words or lines when reading Yes No Cannot line up math columns Yes No Cannot organize space when copying or writing Yes No Handwriting shows inconsistent size, spacing, placement, or does not start at margin Yes No Poor spelling Yes No Words or letters appear to move on the page Yes No Has to reread for comprehension Yes No Reading is slower than average Yes No Comprehension is better read to, versus self-reading Yes No Experiences frustration or avoidance related to academics Yes No Student has IEP Yes No As a result of the IEP your child gets what accommodations?Does your child have a 504 plan? Yes No What accommodations does your child get through their 504?Are there any other complaints your child makes concerning vision?Do you have any other concerns/observations concerning your child's vision?DEVELOPMENTAL HISTORY:Length of Pregnancy:Type of Delivery:Delivery by Forceps/Vacuum:Anesthesia:During the pregnancy of this child, did any of the following occur? Toxemia Trauma Use of alcohol Smoking Injury by fall Use of Drugs Severe illness Prescription Medication little obstetrical care My child is: Biological Adopted Foster Other At what age?Explain:How is your child performing compared to others his/her age?How well developed is your child's spoken vocabulary?Has your child undergone any of the following testing/treatment/therapy?Educational: Yes No Neurological: Yes No Psychological: Yes No Occupational: Yes No Speech/Auditory: Yes No Physical: Yes No If yes, please list all previous evaluations done on your child:Current grade in school:School:What is their favorite subject?Is the child's condition the result of an accident or injury?Explain type of injury/accident, and how received:Date of injury: MM slash DD slash YYYY Address Street Address Address Line 2 City ZIP / Postal Code Health Professional Name:PhoneClaim #Review of Systems: For school-age child1. EyesFlashes Yes No Floaters Yes No Tearing Yes No Itching Yes No Double vision Yes No Burning Yes No Matted Eyelashes/Lashes Sticking Together Yes No Light sensitivity Yes No Redness Yes No Discharge Yes No Other Yes No 2. SyndromeAutism Yes No Asperger's Yes No Attention Deficit Yes No Cerebral Palsy Yes No Chromosomal Disorder Yes No Downs Syndrome Yes No Agenesis Corpus Callosum Yes No Other Yes No 3. VascularCVA Yes No Heart Disease Yes No High Blood Pressure Yes No Anemia Yes No Other Yes No 4. RespiratoryAsthma Yes No Bronchitis Yes No COPD Yes No Other Yes No 6. EndocrineDiabetes Type I Yes No Diabetes Type II Yes No Thyroid Dysfunctio Yes No Hormonal Dysfunction Yes No Other Yes No 7. AllergiesEnvironmental Allergies Yes No to what?Drug Allergies Yes No to what?Food Allergies Yes No Other Yes No 8. MusculoskeletalArthritis Yes No Other Yes No 9. GastrointestinalCeliac Disease Yes No Crohn's Disease Yes No Ulcer Yes No Colitis Yes No Acid Reflux Yes No Other Yes No 10. GenitourinaryKidney Disease Yes No STD Yes No Other Yes No 11. IntegumentaryHerpes Simplex/Cold Sores Yes No Herpes Zoster/Shingles Yes No Rosacea Yes No Psoriasis Yes No Eczema Yes No Other Yes No 12. NeurologicalHead Injury Yes No Concussion Yes No Hydrocephalus Yes No Brain Tumor Yes No Tic Yes No OCD Yes No Other Yes No 13. ConstitutionalCancer Yes No Fatigue Syndrome Yes No Developmental Disorder Yes No Other Yes No If yes to any, please specifyAny other condition that is not listed above? Δ
