Concord Eye Center Pediatric Medical History Form

Concord   E ye   C enter  

Pediatric   M edical   H istory   F orm  

Name:      

 

 

 

 

 

 

 

 

Date:              

Date   o f   B irth:   _ _______________       S ex:                                                         A ge:                                                           D ate   o f   L ast   E ye   E xam:   _ ________________  

Parent(s)Name(s):________________________________                                                                       E -­‐Mail   a ddress:   _ _____________________  

Primary   C are   D octor:   _ ___________________   D id   t his   d octor   r efer   y ou?   (     ) Y   o r   (     ) N       R eferring   D octor:______________  

Current   M edications   ( Prescription   a nd   o ver-­‐the   c ounter):   _ __________________________________________________  

__________________________________________________________________________________________________  

Does   y our   c hild   h ave   a llergies   t o   a ny   m edications?           Y ES           N O  

If   Y ES,   p lease   l ist   m edications:   _ ________________________________________________________________________  

__________________________________________________________________________________________________  

List   y our   c hild’s   s ignificant   m edical   i ssues   o r   i llnesses:   _ _____________________________________________________  

__________________________________________________________________________________________________  

List   a ll   h ospitalizations   o r   s urgeries:   _ ____________________________________________________________________  

__________________________________________________________________________________________________  

 

Review   o f   S ystems  

Does   y our   c hild   c urrently   h ave   a ny   p roblems   i n   t he   f ollowing   a reas?  

 

YES  

No  

Explanation   o f   P roblem  

EYES  

 

 

Glasses:   H ow   L ong?   _ __     C ontacts   H ow   l ong?___  

–   f ailed   v ision   s creening,   b lurry   v ision   d istant   o r   n ear,  

tearing,   r edness,   i tching,   i rritation,   m isaligned   e yes,   l azy   e ye,  

double   v ision,   h ead   t ilt/turn,   c losing   o r   c overing   o ne   e ye,   d roopy  

 

eye   l ids,   s tyes,   c olor   p roblems,   e tc

GENERAL   H EALTH

 

 

Weeks   P remature______               B irth   W eight______  

-­‐   p remature,   b irth   d efect,   g enetic   d isorder,  

 

developmental   d elay,   l earning   d isability,   A DD,   A DHD,   e tc.

EARS,   N OSE   a nd   T HROAT  

 

 

 

-­‐   h earing   l oss,   e ar   i nfections,   c hronic  

 

cough,   e tc.

CARDIOVASCULAR  

 

 

 

 

–   h eart   o r   b lood   v essel   p roblems

RESPIRATORY  

 

 

 

 

–   a sthma,   b reathing   d ifficulties,   e tc.

GASTROINTESTINAL  

 

 

 

 

–   i ntestinal   o r   d igestive   p roblems

UROLOGICAL/GENITAL  

 

 

 

 

–   u rinary   i nfections,   k idney   d isease

MUSCLES,   B ONES,   J OINTS  

 

 

 

–   J uvenile   r heumatoid   a rthritis,  

 

orthopedic   p roblems,   e tc.

SKIN

 

 

 

 

  –   a cne,   w arts,   r ash,   e tc.

NEUROLOGICAL  

 

 

 

 

–   h eadaches,   h ydrocephalus,   s eizures,   e tc.

PSYCHIATRIC    

 

 

 

 

–   a nxiety,   d epression,   i nsomnia,   e tc.

ENDOCRINE  

 

 

 

 

–   d iabetes,   t hyroid   d isease,   e tc.

BLOOD/LYMPHATIC  

 

 

 

 

–   a nemia,   b leeding   i ssues,   e tc.

ALLERGIC/IMMUNOLOGIC  

 

 

 

 

–   h ay   f ever,   a llergies,   l upus,   e tc.

Family   H istory  

 

YES   NO  

Explanation   o f   P roblem  

Eyeglasses   a s   a   c hild  

 

 

 

Lazy   e ye   ( amblyopia)  

 

 

 

Muscle   i mbalance   o r   m uscle   s urgery  

 

 

 

Color   V ision   P roblems  

 

 

 

Any   e ye   d isease   w ith   o nset   i n   c hildhood  

 

 

 

Social   H istory  

Grade   L evel   i n   S chool   ( Learning   a t   g rade   l evel?)  

 

Number   o f   s iblings,   t win   o r   m ultiples  

 

Is   t he   p atient   a dopted?  

 

If   t he   p arents   a re   d ivorced,   w ho   h as   c ustody?  

 

Is   t he   p atient   e xposed   t o   t obacco   s moke?  

 

 

PARENT/LEGAL   G UARDIAN   S IGNATURE:   _ ________________________________________________   D ATE   _ _________  

PHYSICIAN   S IGNATURE:   _ _____________________________________________________________   D ATE   _ __________