Pre-School Child Patient Form Patient Form - Pre-School Child Date MM slash DD slash YYYY Patient Name: First Middle Last M F DOB: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Home Phone:Cell #:Preferred Contact Name & Number: E-Mail Address Grade Level Name of School: Household Members, if applicable (First and last name)Parent/Legal Guardian 1: Parent/Legal Guardian 2 List all siblings and their ages Add RemoveWere you referred to our office? Yes No Whom may we thank for referring you?Please fill out name, location, & contact information of the referral source.Name of professional who referred you: Address of professional who referred you: Street Address City ZIP / Postal Code Phone:FAXEmail Do we have permission to communicate findings with referral source? Yes No How did you hear about us? MEDICAL HISTORY:Pediatrician's Name: Phone #:Address Address Line 2 City State / Province / Region ZIP / Postal Code Last Visit Date MM slash DD slash YYYY is your child especially afraid of doctors? Yes No For what Reason? is your child generally healthy? Please list any food or medication allergies your child has, along with the associated reaction. Add RemoveList significant illnesses, bad falls, high fevers or chronic illnesses:Event/Condition AgeSeverity Complications Event/Condition AgeSeverity Complications Has your child received a neuropsychological evaluation? Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Has your child received a Occupational Therapy evaluation? Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Has your child received a Speech Therapy evaluation? Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Has your child received a Physical Therapy evaluation? Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Has your child received a Developmental Therapy evaluation? Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Behavioral Therapy: Yes No Treatment? Yes No Other Therapy: Yes No Explain VISUAL HISTORY:The main reason for having an examination today: Date of last examination: MM slash DD slash YYYY Doctor's Name: First Last Reason for examination Were glasses, contact lenses, patches, drops, or other optical devices recommended? Yes No Are they used? Yes No When? Why? Results/recommendations: Do you observe or does your child report any of the following:1. Eye Turn Yes No in out 2. Has your child ever had surgery for an eye turn? Yes No 3. Complains of Double Vision Yes No 4. Has your child ever been treated with an eye patch for a visual condition? Yes No How many hours 5. Squint or blinks a lot. Yes No 6. Covers or closes one eye Yes No 7. Lacks interest looking at objects Yes No 8. Rubs eyes excessively Yes No 9. Red or encrusted eyelids Yes No 10. Eyelid droops Yes No 11. Poor tracking/eye movements Yes No 12. Tracks with head rather than with eyes Yes No 13. Head tilt/face turn Yes No 14. Child complains of blurry vision Yes No 15. Eyelid complaints: eyes hurt, burn, or tired Yes No CHECK ALL THAT APPLY: Eye contact not at expected level Body image awareness not at expected level Point/share concepts not at expected level Crossing midline not at expected level Drawing skills not at expected level Loses visual attention easily Puzzle work not at expected level Complains of headaches frequently Tracing skills not at expected level Gets carsick Writing skills not at expected level Poor gross motor skills Number/letter recognition not at expected level Poor fine motor skills Word reconition not at expect level Has had vision therapy before Are there any other complaints your child makes concerning his/her vision?” Do you have any other concerns/observations concerning your child's vision DEVELOPMENTAL HISTORY:Length of pregnancy:Type of Delivery: Forceps/Vacuum Used? Oxygen given at birth? Yes No Anesthesia given at birth? Yes No During pregnancy of this child, did any of the following occur? Toxemia Trauma Use of Alcohol Use of Drugs Severe Illness Prescription Medication Please explain: Child’s birthweight (lbs./oz.):Length:My child is: Biological Adopted Foster Other at what age? Explain: SKILLS/MILESTONES:GROSS MOTOR ACTIVITY: How is your child performing compared to other children of his/her age? FINE MOTOR ACTIVITY: How is your child performing compared to other children of his/her age? LANGUAGE ACTIVITY: How is your child performing compared to other children of his/her age? How well developed is your child's spoken vocabulary? How well developed is your child receptive vocabulary? Does anyone in your child’s biological family have a history of any of the following conditions?1. Eye Turn Yes No Who 2. Amblyopia (lazy eye) Yes No Who 3. Learning Disability Yes No Who 4. Diabetes Yes No Who 5. Arthritis Yes No Who 6. Glaucoma Yes No Who 7. Blindness Yes No Who 8. High Blood Pressure Yes No Who 9. Breathing Problems Yes No Who 10. Retinal Disease Yes No Who 11. Cancer Yes No Who 12. Skin Conditions Yes No Who Is the child's condition the result of an accident or injury? Explain type of injury/accident, and how received: Date of injury: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Insurance Agent/Adjuster Name First Last PhoneClaim # REVIEW OF SYSTEMS:For Pre-school age childDoes your child have a personal history of any of the following conditions?1. SyndromeAutism Yes No Asperger's Yes No Attention Deficit Disorder Yes No Cerebral Palsy Yes No Chromosomal Disorder Yes No Down syndrome Yes No Agenesis Corpus Callosum Yes No Other 2. VascularCVA Yes No Heart Disease Yes No High Blood Pressure Yes No Anemia Yes No Other 3. RespiratoryAsthma Yes No Bronchitis Yes No COPD Yes No Other 4. EndocrineDiabetes Type I Yes No Diabetes Type II Yes No Thyroid Dysfunction Yes No Hormonal Dysfunction Yes No Other Environmental Allergies Yes No to what? Drug Allergies Yes No Food Allergies Yes No to what? Other 6. MusculoskeletalJuvenile Arthritis Yes No Other 7. GastrointestinalCeliac Disease Yes No Crohn's Disease Yes No Ulcer Yes No Colitis Yes No Acid Reflux Yes No Other 8. GenitourinaryKidney Disease Yes No Other 9. IntegumentaryPsoriasis Yes No Eczema Yes No Other 10. NeurologicalHead Injury Yes No Concussion Yes No Hydrocephalus Yes No Brain Tumor Yes No Tic Yes No OCD Yes No Seizure Disorder Yes No Other 11. Constitutional Cancer Yes No Developmental Disorder Yes No Other If yes to any condition, Please explain: Any other condition that is not listed above?
