ChildIntake Form Please fill out this intake form before your appointment. "*" indicates required fields Step 1 of 5 20% PATIENT INFORMATIONFirst Name* Last Name* Date of Birth* Parents Name* Home Phone*Cell PhoneEmail* Who may we thank for referring you to our office? Family/Friend Professional Referral Source's Name If not referred, how did you choose our office? This information is confidential and critical for the evaluation of your vision and health.SCHOOL PERFORMANCEIn order to assist the doctor in evaluating visual skills needed in the learning environment, please grade and then check all boxes that apply.1-Below Average2-Average3-AdvancedMath Penmanship Physical Ed Reading Spelling Writing Other academic performance issues: Does not enjoy reading Errors when copying Excessive eye rubbing Fatigue or daydreams often Hearing, auditory processing or speech problem Honours Curriculum Labeled as ADD/ADHD Poor reading comprehension Lose place when reading Reverses words/letters Prefers being read to Slow reader Short attention span Teacher has concerns about school performance Special Education Any of the following therapy Occupational Physical Psycho - Educational Speech Other More to share in private Other therapy VISUAL HEALTHDate of Last Eye Exam By Whom? Do you currently wear glasses? Yes No Any problems with your current contacts or glasses Use Sports Goggles/Safety Glasses Yes No PATIENT MEDICAL HISTORYName of Family Physician Physician Address Date of Last Physical Check-up CURRENT MEDICATIONS (RX or Over the Counter)Allergies to medications? Yes No If so, please list: FAMILY MEDICAL/EYE HISTORY (CHECK ALL THAT APPLY)OcularBlindness Personal Family Blindness Relation Cataracts Personal Family Cataracts Relation Corneal Problems Personal Family Corneal Relation Dyslexia Problems Personal Family Dyslexia Relation Glaucoma Problems Personal Family Glaucoma Relation Lazy Eye/Eye Turn Personal Family Lazy Eye/Eye Turn Relation Retinal Problems Personal Family Retinal Relation Macular Degeneration Personal Family Macular Degeneration Relation MedicalADD/ADHD Personal Family ADD/ADHD Relation Allergies Personal Family Allergies Relation Arthritis Personal Family Arthritis Relation Cancer Personal Family Cancer Relation Diabetes Personal Family Diabetes Relation Eczema/Rashes Personal Family Eczema/Rashes Relation High Blood Pressure Personal Family High Blood Pressure Relation High Cholesterol Personal Family High Cholesterol Relation Kidney Personal Family Kidney Relation Neurological Personal Family Neurological Relation Psychological Personal Family Psychological Relation TBI/Stroke Personal Family TBI/Stroke Relation Thyroid Personal Family Thyroid Relation Have you ever experienced, been diagnosed or treated for any of the following? Blurry Distance Vision Blurry Near Vision Burning Difficulty Driving at Night Double Vision Eye Fatigue/Strain Eye Infections Eye Injury Flash of Light Floaters/Spots Glare or Reflection Grittiness Headaches Itchiness Occasional Dryness Sunlight Sensitivity Tearing Uncomfortable Glasses NameThis field is for validation purposes and should be left unchanged.