Health History - Pediatric

Health History Form & Lifestyle Questionnaire

PATIENT INFORMATION

Child’s Name*

Date of Birth*

Pediatrician / Location*

Date of last physical exam*

EYE Doctor / Location*

Date of last EYE exam*

What is the main reason for your visit today?*

SPECTACLE/CONTACT LENSES

Does your child presently wear glasses?*

Does your child presently wear contact lenses?*

EYE / VISION PROBLEMS*

(Check all that apply.)

EYE HISTORY*

(Check all that apply.)

Amblyopia ("lazy eye")

Color Vision Deficiency*

Blindness*

Strabismus ("eye turn")*

Eye Injury*

Eye Surgery*

Other eye / vision problems (other than glasses)*

MEDICAL HISTORY

List any medical conditions your child has

Review of Systems*

Please check the boxes that apply. Unchecked boxes will mean “no”.

Allergic Disorders*

Cardiovascular*

Constitutional*

Endocrine*

Gastrointestinal*

Genitourinary*

Ear/Nose/Mouth/Throat*

Hematologic*

Immunologic*

Integumentary*

Musculoskeletal*

Neurological*

Psychiatric*

Respiratory*

SURGICAL HISTORY

(List any surgeries your child has undergone):*

EYE MEDICATIONS

(List any eye drops, including over-the-counter eye medications)*

SYSTEMIC MEDICATIONS

(List all current medications and supplements as well as side effects)*

SOCIAL HISTORY*

DEVELOPMENTAL HISTORY

Child’s birth weight:*

Were there any complications with pregnancy or at birth?*

Was your child born premature?*

Was there any use of alcohol, drugs, medication, or cigarettes during the pregnancy?*

EDUCATIONAL HISTORY

Current Grade:*

Has your child ever repeated a grade?*

Does your child receive any special services from the school? (e.g. speech and language, occupational therapy, reading remediation)*

Was there any use of alcohol, drugs, medication, or cigarettes during the pregnancy?*

Does your child like school?*

Is your child performing at his/her potential at school?*

Is your teacher satisfied with your child’s school performance?*

Is your child in the grade level expected for his/her age?*

Does your child read as well as others in the same grade?*

COMPUTER / VIDEO GAME USE

Does your child use a computer?*

Hand-held video game?*

Does your child experience symptoms when using devices: (Check all that apply)*

COMPUTER / VIDEO GAME USE

What sports / recreational activities does your child participate in?*

Does your child use any eyewear for sports?*

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