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?
Does your child presently wear glasses?
Does your child presently wear contact lenses?
(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):
List any medical conditions your child has
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
(List any surgeries your child has undergone):
(List any eye drops, including over-the-counter eye medications)
(List all current medications and supplements as well as side effects)
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?
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)
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?
Does your child use a computer?
Hand-held video game?
Does your child experience symptoms when using devices: (Check all that apply)
What sports / recreational activities does your child participate in?
Does your child use any eyewear for sports?
All EyeCare Services
KeepIn Touch
At A+ Vision Optometry, we provide the highest quality eye care to all our patients. Schedule your appointment today.
We've copied your review, after you click 'Publish' please paste your review by selecting 'ctrl' + 'v' into the review comments section.
One fine body…
