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)Father: Siblings: Father: Siblings: Mother: Siblings: Mother: Siblings: Guardian: Siblings: Were you referred to our office? Yes No Who Referred 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 doctor's? Yes No For what Reason? is your child generally healthy? Allergies? Last significant illnesses, bad falls, high fevers or chronic illnesses:Event/Condition AgeSeverity Complications Event/Condition AgeSeverity Complications Neuro/psych evaluation Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Occupational Therapy Evaluation: Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Speech Therapy Evaluation: Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: Physical Therapy Evaluation: Yes No Treatment? Yes No By whom Approximate date: MM slash DD slash YYYY Frequency: 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. Complains of Double Vision Yes No 3. Had Surgery for eye turn Yes No 4. Is being treated with patching? 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 visio 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: Biologica 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? Please list the biological Family member in your child's life that has the following:1. Eye Turn ? Yes No Who 2. Amblyopia? 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 Adjuster Name: First Last PhoneClaim # REVIEW OF SYMPTOMS:For Pre-school age child1. SyndromeAutism Yes No Asperger's Yes No Attention Deficit Disorder Yes No Cerebral Palsy Yes No Chromosomal Disorder Yes No Downs 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. Neurological<.b>Head 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?
