Foley Vision Center
About Us
Vision Therapy
Our Services
Sports Vision
Patient Forms
One-Minute Eye Exam
Eye Games

Existing Child Patient Form

GENERAL INFORMATION
Full Name:
Preferred Name:
Birth Date:
Phone(hm):
Address:
City:
State:
Zip:
Mother:
Father:
Mother's Email:
Father's Email:
Mother's Cell:
Okay to text
Father's Cell:
Okay to text
Mother's Employer:
Father's Employer:
Please fill out below if Insurance has changed since your last visit...
Insurance Company Name (Vision):
Name of Primary Member:
ID #:
Insurance Company Name (Medical):
Name of Primary Member:
ID #:
Primary Care Physician:
Preferred way to contact you: Email
Home Phone
Cell Phone
Work Phone
Referred By:
School:
Grade:
Teacher:
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiin or Other Pacific Islander
White
Unknown/Decline to Provide
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Decline to Provide
Preferred Language: English
Spanish
Other:

Per the Health Care Act we are required to record your height and weight at each visit.
Height: Weight:

Patients with Insurance: At the time of treatment, patients are expected to pay their estimated charges. An estimate of cost will be provided to you at the time of your appointment. Insurance portion is only an estimate and any balance remaining after insurance payment is patient's responsibility.

Patients without Insurance: Patients without insurance are required to pay the charges in full at the time service is provided. A total cost will be provided to you at the end of your appointment.

Do you plan on purchasing new glasses today? Yes No If RX changed
Reason for Today's Visit:
CHIEF COMPLAINTS TODAY (or over the last week)
Allergies
Blurred Vision Distance
Blurred Vision Near
Burning/Stinging
Discharge
Double Vision
Dryness
Eye Strain/Fatigue
Floaters/Spots
Flashes
Glare/Sensitivity to Light
Foreign Body Sensation
Headache
Itching
Loss of Vision
Loss of Side Vision
Pain/Discomfort
Redness
Scratchy/Gritty
Watering/Tearing
Is there any evidence from school or psychological tests that some visual malfunction may be present? Yes No
If so, what?
GLASSES
Does child wear glasses? Yes No
Single Vision
Progressive
Bifocals
Trifocals

For:
Near
Distance
Both
Any Problems?
CONTACTS
Does child wear Contacts? Yes No
Full Time
Occasional
Rarely


Type of contacts?
Daily Wear
Extended Wear
Soft Toric
Gas Permeable
Bifocal/Progressive
What cleaning solution do you use?
Average Wear Time: hours.
Wear Time Today: hours.
Any Problems?
Have you ever noticed the following:  Y  N When?
Child feeling sick when reading in the car
Eyes frequently reddened
Frequent eye rubbing
Frequent blinking
Closing or covering one eye
Head close to paper when reading or writing
Tilting head when reading or writing
Confuses letters or words
Reverses letters or words
Skips, rereads or omits words
Vocalizes when reading silently
Reads slowly
Uses finger as a marker
Poor reading comprehension
Writes or prints poorly
Tires easily
Avoids near tasks
Short attention span
Poor motor coordination
Difficulty catching/hitting a ball
Television viewing:
How much:
How often:
Viewing distance:
MEDICAL HISTORY
Does your child have any allergies to medications?
Yes No
If yes, please explain:
Other Allergies (foods, pollens, etc.):
List any medications child takes:
Rx or OTC/SupplementsCondition
Has your child been treated with Accutane currently or previously?
Yes No
Has your child been diagnosed as having:
Learning disabilities
Developmental delays
ADD or ADHD
Cerebral Palsy
Seizure disorders
Autism
Asthma
Hay Fever
Other Problems:
Has a neurological or phychological evaluation been performed?
No
Yes (please specify)
By Whom
Results?
Our goal is to provide the best, most complete, up-to-date care available. Our philosophy is preventive and developmental in approach. To provide this service in the most efficient manner, please be aware of the following office policies:
  • Fees for services are due at the time those services are rendered.
  • Payment in full at time of ordering.
  • We reserve the right to charge for missed appointments not canceled in advance.
  • Vision Therapy patients must notify us of absences in advance.
  • There is a charge for written reports.
  • Responsibility for payment is the patient's. Insurance agreements are between the company and the patient. We will assist with proper forms but require reimbursement from patients.
Signed (type your name):
Date: