Foley Vision Center
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New 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?


Have you ever noticed the following:  Y  N When?
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.):
Has the child taken or is taking Accutane medication?
Yes No
List any medications child takes:
Rx or OTC/SupplementsCondition
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?
Does your child currently receive:
Occupational therapy services
By Whom? Results?
Physical therapy services
By Whom? Results?
Speech therapy services
By Whom? Results?
Nutrition Information:
Current diet: Excellent Good Fair Poor
Is your child: Moderately Active Extremely Active
Does your child crave sweets? Yes No
Periods of: Very high energy? Yes No
Low energy? Yes No
MEDICAL AND FAMILY HISTORY
OCULAR:
Self Family Who?
Amblyopia (Lazy eye)
Blindness
Cataract(s)
Color Deficiency
Glaucoma
Macular Degeneration
Ptosis (Drooping Lid)
Retinal Detachment
Retinal Tear
Strabismus (eye turn)
Other:
MEDICAL:
Self Family Who?
Androgen Deficiency
Arthritis
Acne Rosacea
Diabetes
Cancer
Facial Herpes Zoster (Shingles)
Heart Disease
Hepatitis C
High Blood Pressure
Kidney Disease
Lupus
Migraines
Sarcoidosis
Sleep Disorders
Stroke
Thyroid Disease
Other:
DEVELOPMENTAL HISTORY
Please check all that apply:
Normal Term Birth (full term)
Premature Term Birth
Low Birth Weight
Over Term Birth
Complications at Birth
Crawled normally
Did not crawl for long
Crawled longer than usual
Walked at months
High fevers
Normal temperament
Becomes irritable
Learning difficulties
Speech Difficulties
Reduced fine-motor skills
Reduced gross-motor skills
Childhood concussion
Bad Fall(s)
Head injuries
SCHOOL
Age entering Kindergarten:
First Grade:
Does child like school? Yes No
Teacher? Yes No
School work is: Above Average
Average
Below Average
Do you feel your child is working up to potential? Yes No
Does teacher feel your child is up to potential? Yes No
What subjects come easy for child?
Does child like to read? Yes No
Voluntarily? Yes No
What?
Specifically describe school difficulties:
Grade been repeated? Yes No
Which?
Changed schools often? Yes No
When?
Does child seem to be under tension or extreme pressure when doing school work? Yes No
Has child had any special tutoring and/or remedial assistance? Yes No
When?
From Whom?
Where?
How Long?
Results:
How well developed is the child's vocabulary?
VISUAL HISTORY
Previous eye exam: Doctor's Name:
Date:
Results:
Were glasses prescribed? Yes No
Are they worn? Yes No
When?
Members of the family who have had visual attention and why:
Name Age Visual Situation
GENERAL BEHAVIOR
Are there any problems at...
School Yes No
Home Yes No
What causes these problems?
Child's reaction to fatigue: Sad
Irritable
Other:
Child's reaction to tension: Nail Biting
Thumb Sucking
Other:
Give a brief description of your child as a person:
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?
FAMILY AND HOME
Please indicate which adult child lives with:
Mother Step Father Aunt
Father Step Mother Uncle
Grandmother Grandfather Adopted Parents
Foster Parents Other:
Has the child ever been through a traumatic family situation (divorce, parental loss, separation, etc.) Yes No
What age was the child?
Does the child seem to have adjusted? Yes No
Is family life stable at this time? Yes No
How does the child get along with...
Parents:
Siblings:
Classmates at school:
Playmates at home:
Learning problem history:
Father or someone in his family.
Who?
Mother or someone in her family.
Who?
Patient's sibling(s)
Who?
To what extent?
History of mental retardation, psychological disturbance, etc. on either side of family.
Who?
REPORT POLICIES
Would you like copies of any reports? Yes No
Copies sent anywhere? Yes No
Name:
Address:


Please sign to give us permission to release this info to the above sources. (Valid for 90 days only)
Signed (type your name):
Date:
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: