Online Child Patient Forms (19 and under)

Patient information

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Billing information

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Please choose from the menu options or select the option to type in your own text. Thank you!



Eye History

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Contact Lens Wearers Only


Family Eye History

Does anyone in your family have any of these eye conditions?





Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Review Of Systems

Social History

Vision Therapy History


Medical History


List significant illnesses, bad falls, high fevers or chronic illnesses:


Developmental History:


During pregnancy of this child, did any of the following occur:


@birth

My child is:


Skills / Milestones





Has your child undergone any of the following testing / treatment/ therapy?


Visual History


Do you observe or does your child report any of the following?


Strabismus / Amblyopia History

TBI History

What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?


Brain Injury Vision Symptom Survey

Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4



If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:




Dry Eye History


Over the past week, which of the following eye symptoms have you experienced?


Reading and Computer Symptom Checklist


CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)


Please answer the following questions about how your eyes feel when reading or doing close work.


NOTE: if the patient is a child, please read the instructions and then each item exactly as written.


Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4


Check All That Apply:



Dizziness And Motion Sensitivity Checklist