Child History Forms | Eye Doctor in Houston, TX

Name*

First Last

Preferred Name

Date of Birth

Gender

Male

Female

Age

Grade

School

Mother/Guardian Name

Mother/Guardian Occupation

Father/Guardian Name

Father/Guardian Occupation

Parents Status

Married

Divorced/Separated

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Other Phone

Which phone you Preferred

Home Phone

Cell Phone

Other Phone

Non-Guardian Emergency Contact

Emergency Contact Phone Number

Primary insurance

Secondary Insurance

Family Eye Doctor

Last Eye Exam

Referred By: (Check all that apply)

Medical Information

Pediatrician’s Name

Date of Last Exam

Does the Pediatrician have any areas of concern regarding the child’s health?

Have you received any of the following examinations? Check any that appy and write down in the name of the provider.

Neuropsychological

Occupational Therapist

Speech/Hearing Specialist

Other Specialist

Name of the provider (If Other Specialist)

Results/Recommendations

History of Head Injury/Stroke/Other Neurological Insult

Born Premature or Complications at Delivery

Developmental History

Delays in gross motor development?

i.e. difficulties learning to ride a bike, catch a ball, play sports, etc.

Yes

Delays in fine motor development?

i.e. difficulties learning to use scissors, tie shoes, draw/write, etc

Yes

Delays in learning to crawl or walk?

Please note if child skipped crawling

Yes

Other Developmental Delays

Yes

Take Our Convergence Insufficiency Symptom Survey

Did your child repeat a grade or have a delayed start?

Yes

Has your child received special tutoring or remedial assistance?

Yes

Do you have any concerns about your child’s behavior?

Yes

Has your child ever had a head injury/stroke/Other Neurological Insult?

Yes

Is your child performing up to their potential?

Is there any other information you feel would be helpful/important in our treatment of your child?

Strabismus / Amblyopia

Wandering, Crossed or Lazy Eyes – Select all that apply

Direction of wandering eye?

Inward

Outward

Down

Which Eye?

Right

Left

Both

At what age did you or others first notice the eye wander?

Have reduced vision in one eye even after corrected with glasses?

Right Eye

Left Eye

Both Eyes

Neither

Patching

Yes

Kind of patching?

Black patch

Eye Drops

Other

At what age was your child first diagnosed with Amblyopia?

Reduced vision in one eye with glasses

At what age did your child start wearing glasses?

Patient’s Name

First Last

Date of Birth

Date

Review of Symptoms

Please mark each box. Indicate Yes or No for any current diagnoses or symptoms for the following.

General Constitutional

Unexplained fever, weight loss or gain, etc

Yes

Eyes

Disease related such as Glaucoma, Detached Retina

Yes

Ears, Nose, Throat, Mouth

Hearing loss, chronic nasal congestion, chronic cough

Yes

Respiratory

Asthma, chronic bronchitis, shortness of breath, etc

Yes

Cardiovascular

Diabetes, hypertension, heart problems, etc

Yes

Gastrointestinal

Diarrea, constipación, hernia, ulcers, etc

Yes

Genitourinary

Painful urination, frequent urination, jaundice, etc

Yes

Hematological / Lymphatic

Anemia, bleeding problems, etc

Yes

Musculoskeletal

Muscle Pain, trauma, osteoarthritis, osteoporosis, etc

Yes

Skin

Eczema, Psoriasis, rases etc

Yes

Neurological

Epilepsy, Cerebral Palsy, tumor, etc

Yes

Psychiatric

ADHD, Depression, anxiety, etc

Yes

Endocrine

Diabetes, Thyroid problem, etc

Yes

Allergic / Immunological

Yes

Personal Medical History

Please list all current medications

Does the patient have any of the following illnesses or conditions?

Please check and describe in the list below

Description of above or other conditions

Does the patient have any of the following eye conditions?

Please check and describe in the list below

None

Glaucoma

Blindness

Retinal Detachment

Cataracts

Strabismus

Macular Degeneration

Amblyopia

Description of above or other eye conditions

Family Medical History

Check each one Yes or No to indicate of any member of your family has had these diseases. Family history includes your parents, grandparents, siblings, and your children.

Blindness

Yes

Cataract

Yes

Macular Degeneration

Yes

Glaucoma

Yes

Retinal Detachment

Yes

Lupus

Yes

Strabismus

Eye turn or crossed eyes

Yes

Amblyopia

Lazy Eye

Yes

Dyslexia

Or other reading problems

Yes

High Blood Pressure

Yes

Heart Disease

Yes

Thyroid Disease

Yes

Diabetes

Yes

Cancer

Yes

Other

Yes

Other Family Medical History

Social History

Please answer the following questions. For young children you can select N/A.

Do you currently or have you in the past used tobacco products?

Yes

N/A

Please describe your alcohol consumption:

How many days per week you drink and how many drinks you have in an average week? For young children you can write N/A

If you use them, please describe your use of Recreational/Street drugs

How long you have taken them, what type, the amount taken, and the frequency of taking them?

Female: Are you pregnant?

Yes

N/A

Patient lives with

Both Parents

Single Parent

N/A

Is the patient exposed to second hand smoke?

Yes

Who else lives at home with the child

Siblings

Others

Number of children at home

Visual Signs & Symptoms Checklist

Name

Date of Birth

Reading & Work

Sports & Coordination

Accident Prone

Poor Coordination

Poor Balance

Dislikes sports/physical activities

Poor performance in sports/physical activities

Poor Rhythm and timing

Poor depth perception

Visual Perception

Visual Discrimination - Visual Figure-Ground

Difficulty finding a specific piece of information on a page or in a situation

Difficulty with getting lost in the details

Easily frustrated or fatigues quickly with too much print on a page

Visual-Motor Processing Issues

Difficulty with visually guided motor activities

Poor handwriting

Difficulty writing within the lines or margins

Difficulty copying from a book or a whiteboard

Frequently drops utensils or knocks over drinks

Form Constancy Issues

Difficulty recognizing letters, words, or numbers, especially if the size, font, or color changes

Confuses lefts and rights

Difficulty recognizing the same objects in different situations.

Difficulty recognizing letters, words, or numbers, especially if presented differently (i.e., paper, book, or board)

Difficulty building or putting together something from a set of instructions

Visual Closure

Difficulty identifying an object when only parts are visible (example: truck but missing wheels, or a person if missing facial features)

Difficulty with spelling or reading because they can't recognize a word if a letter is missing

Visual-Spatial Issues

Difficulty telling where objects are in space

Difficulty with depth perception or judging how far things are from them and from each other

Poor balance or coordination

Difficulty with crowding when writing

Difficulty with telling time, reading maps, and/or judging time

Often trip, falls, or bumps into things

Prone to getting lost

Long or Short-Term Visual Memory Issues

Difficulty recalling what has been seen

Difficulty with recognizing familiar words either recently or from page-to-page

Difficulty with spelling familiar words or words they have practiced many times

Difficulty remembering what they have read

Difficulty using a keyboard or calculator

Visual Sequencing Issues

Difficulty telling the order of symbols, words or images

Difficulty in writing answers on a separate sheet

Difficulty with spelling familiar words or words they have practiced many times

Long Lasting (Chronic) Condition

Chronic health problems

Light sensitivity

General fatigue

Headaches

Weight loss

Eye pain

Hormone imbalance

Digestion

Recent (Acute) Condition

Excess Condition

Uncoordinated

Lazy eye

Tunnel vision

Head tilt/turn

Asthma

Double vision

Weight gain

Eye turn in

Emotional Fatigue

Reactive Condition

Emotional/Post-traumatic Condition

Release of Information

IT IS OFTEN BENEFICIAL TO US TO DISCUSS EXAMINATION RESULTS AND TO EXCHANGE INFORMATION WITH OTHER HEALTH CARE PROFESSIONALS INVOLVED IN YOUR CARE. PLEASE SIGN BELOW TO AUTHORIZE THIS EXCHANGE OF INFORMATION.

I'm the Parent of and undersigned give Eye Therapy, permission to release any Protected Health Care Information regarding my medical records, including diagnosis to other health care professionals, specifically, but not limited to those listed below, when it is necessary for the treatment of my visual condition.

Primary Care Physician/Clinic

Other Doctor/Clinic

Primary Eye Doctor/Clinic

School District

Other Family Member: (Relationship)

Signatures

Name of the signer below

Name of the Child

Parent’s or Guardian’s Signature (Initial)

Date

Expires on

End of Treatment

Specific Date

Relationship to Patient

Insurance – Only an Estimate

Eye Therapy is willing to provide you with an ESTIMATE of what your insurance will or will not cover. However, we cannot and do not guarantee that the ESTIMATE we provide is correct. When we as the provider or you call in to get the ESTIMATE it is given with the statement “this is not a guarantee of payment”. Please understand that while we will assist you in understanding your benefits, we have no influence over your coverage. You are ultimately responsible for all fees and charges on your account.

I understand that payment in full is due at time of service unless other arrangements have been made.

Authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I also give permission for Eye Therapy to release any Medical Records requested by my insurance company for claim processing. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.

Thank you,

I have read and accept this policy,

Patient name

Responsible party name

Signature of Parent/Guardian (Initial)

Date

Statement of Privacy Practices

Our office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend your privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our vision and medical care operations. Your personal health information will never be otherwise given to anyone, even family members, without your written consent. You, of course, may give written authorization for us to disclose your information to anyone that you choose, for any purpose.

Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information
We will only request personal information needed to provide our standard of quality vision and medical care, implement payment activities, conduct normal optometric practice operations, and comply with the law. This may include your name, address, telephone number(s), social security number, employment data, medical history, and health records. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law

Disclosure of Protected Health Information
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and government officials under certain circumstances. We will not use your information for third party marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments, including voice mail messages, answering machines, postcards, and email.

Patient Rights
You have the right to request copies of your healthcare information and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

Responsible party name

HIPAA Privacy Practice Acknowledgment

I have received or was offered and declined a notice of privacy practices.

Patient name

Signature of Parent/Guardian (Initial)

Date

Relationship to Patient

Name

Date of Birth

10-Point Scaled Symptom Survey

On a scale from 0-10 (10 being most severe) how severe are the following symptoms while doing visual tasks?

Headaches

In general including frequency and severity

Comments

Eye strain

soreness, pain, or discomfort

Comments

Eyes get tired and generally become tired

Comments

Double vision, shadowing of letters, words move, jump, swim, appear to float on the page

Comments

Blurry Vision even though glasses are on or have been told glasses are unnecessary

Comments

Loss of place, skipping words and/or lines while reading, or have to reread the same line of words

Comments

Motor Coordination/Difficulties with Depth perception

accident prone, poor hand-eye coordination, avoid or have poor performance in sports, frequently knock things over, trip, fall, or run into things, poor rhythm/timing

Comments

Academic Concerns

Poor Interest in reading and school, poor reading comprehension, poor grades, homework takes longer than it should, poor handwriting

Comments

Visual Perceptual Difficulties

Letter reversals, confusion with words, letters, numbers, symbols, get lost in details, fatigues or becomes confused with too much info on page, confused with different fonts, poor visual recall

Comments

Balance/Dizziness/Vertigo/Disorientation/Nausea

Comments

Poor attention, focus, concentration, hyperactivity

Comments

Brain fog, sensory overstimulation, motor overload

Unable to think clearly with too much stimulus, overwhelmed with too much light, sound, busy visual environments/patterns, unable to sit still or reflexive movements due to overstimulation

Comments

Behavior problems, poor self-esteem/confidence, easily frustrated, anxiety, depression

Comments

Eye wanders or crosses

Comments

Other - please describe

difficulty with multitasking, auditory processing difficulties, etc.

Comments

Total Score

Do you consent to receive text messages?

Yes

Location / Branch

CAPTCHA

Child Welcome Form

Medical Information

Developmental History

Take Our Convergence Insufficiency Symptom Survey

Strabismus / Amblyopia

Review of Symptoms

Personal Medical History

Family Medical History

Social History

Visual Signs & Symptoms Checklist

Visual Perception

Release of Information

Signatures

Insurance – Only an Estimate

Statement of Privacy Practices

HIPAA Privacy Practice Acknowledgment

10-Point Scaled Symptom Survey

Energy Corridor

Lantern Lane

Pasadena

Sealy

New Caney