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Home » Contact Us » Patient Medical History Forms » Online Child Examination Questionnaire & History Form

Online Child Examination Questionnaire & History Form

Child Examination Questionnaire (17 and under)

  • CHILD EXAMINATION QUESTIONNAIRE FOR PARENTS

  • Example: 9 years old and 8 months.
  • School History

  • GENERAL BEHAVIOR

  • Signs of Eye Teaming Problems

  • Signs of Focusing Problems

  • Signs of Tracking Problems

  • Signs of Visual Processing Disorders

  • GENERAL HEALTH

  • Previous Vision History

  • PERSONAL AND MEDICAL BACKGROUND INFORMATION

  • The NEW Daytona Optomap Retinal Examination is prescribed by Dr. Roth to evaluate the health of your retina (back part of the eye). It produces a sharp and wide view of your retina, without using eye drops. The advantages to you are:
    1. Fast (less than 1 second per eye).
    2. No blurred vision afterwards.
    3. You will see the back part of your own eye, and the doctor will explain the findings.
    4. This is now part of your permanent record, so we can then compare the retina from year to year.
    This new technology is a part of our standard of care and the fee for this test is $39.00. This test is not covered by any medical insurance.
  • Addresses eye health and eyeglass prescriptions.
  • There are 3 levels; standard, complex, and custom. The fee for this service is separate from the comprehensive examination.
  • This service (1) assesses the fit, positioning, power, corneal health, etc. with your contact lenses on, and then (2) assess your cornea and prescription (refraction) after removing your contact lenses. This additional testing is separate from a Comprehensive Examination. The fee for this assessment starts at $25.00.
  • Brief Questionnaire

  • Example: Near work such as reading, crosswords, cards, crafts.
  • Example: Basketball, Golf, Swimming, Tennis, Racquetball, etc.