Children'S Eye Clinic Medical History Form
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1CHILDREN’S EYE CLINIC, PC
Child’s Name __________________________________________________ Child’s Date of Birth _____________________
1.
Was your child referred to our office by a physician or other medical provider?
YES
NO
Name of referring physician/medical provider _____________________________________________________
2.
Please provide name of child’s primary care physician/provider. _________________________________________
3.
Why is your child being seen today? _______________________________________________________________
4.
Does your child have a history of previous eye problems? If yes, please describe briefly.
YES
NO
5.
Has your child had previous eye surgery? If yes, please describe.
YES
NO
6.
Has your child seen an eye doctor before? If yes, please list name of provider and approximate date of exam.
YES
NO
7.
Is your child up to date on their immunizations?
YES
NO
8.
Was your child born prematurely? If yes, how many weeks early? _________________
YES
NO
9.
Were there any complications of pregnancy or delivery? If yes, please describe briefly.
YES
NO
10. Does your child have any medical problems or handicaps? If yes, please describe.
YES
NO
11. Has your child ever had surgery of any kind? Please describe.
YES
NO
12. Has your child or any relative had a serious complication of anesthesia? If yes, please describe.
YES
NO
13. Is your child adopted? (Skip #14 and #15 if child is adopted and family history is unknown.)
YES
NO
14. Is there any family history of eye problems (other than wearing glasses)? If yes, please describe.
YES
NO
15. Is there any family history of serious medical disease? If yes, please describe.
YES
NO
16. Does your child have any delays in their physical or mental development? If yes, please circle below.
YES
NO
Gross Motor Delay
Fine Motor Delay
Speech Delay
Mental Delay
Reading Delay
17. Grade in school if applicable. ______________________________
Difficulty doing grade level school work?
YES
NO
18. Does your child have any allergies to medications?
YES
NO
If yes, please list.
19. Does your child have any other type of allergies?
YES
NO
If yes, please list.
20. Does your child currently use any eye medications?
YES
NO
If yes, please list.
21. Does your child currently take any other medications?
YES
NO
If yes, please list.
Does your child currently have any of the following problems? If yes, please explain.
General symptoms such as fever, poor appetite, fatigue?
YES
NO
________________________________
Allergy symptoms?
YES
NO
________________________________
Heart problems (heart murmur, irregular heart beat)?
YES
NO
________________________________
Ear, nose and throat symptoms (ear infections, sinus infections, sore throat)? YES
NO
________________________________
Gastrointestinal symptoms (stomach pain, regurgitation, bowel symptoms)? YES
NO
________________________________
Bladder or kidney problems (bladder infection, urinary reflux)?
YES
NO
________________________________
Blood system problems (anemia, excessive bleeding, easy bruising)?
YES
NO
________________________________
Musculoskeletal symptoms (arthritis, low or increased muscle tone)?
YES
NO
________________________________
Neurologic problems (seizures, headaches)?
YES
NO
________________________________
Psychiatric problems (ADD, ADHD, emotional problems)?
YES
NO
________________________________
Respiratory symptoms (asthma, reactive airway, bronchitis)?
YES
NO
________________________________
Skin problems (eczema, rash)?
YES
NO
________________________________
Person completing form: ____________________________________________
Date completed: ________________________
Relationship to child: ________________________________________________
THANK YOU.
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