Online Patient Registration Form Step 1 of 3 33% I am filling this out for(Required) Myself Child CHILD EXAMINATION QUESTIONNAIRE FOR PARENTSToday's Date(Required) MM slash DD slash YYYY Child's full name(Required) First Last Nickname, or likes to be called Date of Birth MM slash DD slash YYYY Age:Brothers/Sisters and their Ages Add RemoveMain concern(s) 4.The Optomap Retinal Examination is prescribed in our office to evaluate the health of your retina (back part of the eye). The advantages to you are: Fast (less than 1 second per eye) No blurred vision afterwards and no need for Dilation in most cases. You will be able to see the back part of your own eye, and the doctor will explain the findings. 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. The fee for this test is $45.00. , This test is not covered by any medical insurance. I choose to have this test(Required) Yes No School HistoryDoes your child like school? Yes No Easiest subject(s): Hardest Subject(s): Please describe if there are or have been any:School-Related or Reading difficulties: Yes No Remedial work or tutoring? Yes No Psychological, Educational, Audiological or other testing performed? Yes No General Health and Vision History:Significant illnesses or conditions? Yes No Any medications? Yes No Last Eye Examination By whom? Were eyeglasses ever prescribed? Yes No Is there a family history of any vision problems? Yes No Significant prior diagnoses or treatments? Yes No GENERAL BEHAVIORPlease place a check mark next to any of the following behaviors that you believe your child exhibits, and next to any problem that seems to occur often High activity level Poor attention span Impulsivity Frustrates easily Doesn’t listen when spoken to Poor memory More active than other children his (her) age Signs of Eye Teaming Problems Covers or closes one eye when reading Rubs eyes Child complains of eyestrain Child complains of headaches Child complains of double vision Child complains of words moving on the page Inattentive Poor reading comprehension Loses place Signs of Tracking Problems Loses place often Must use finger or guide to keep place Skips lines and words often Poor reading comprehension Short attention span Signs of Focusing Problems Child complains of blurred vision Child complains of blurred vision when looking from desk to board Child complains of eyestrain Child complains of headaches Rubs eyes Inattentive Poor reading comprehension Is tired at the end of the day Holds things very close Child complains of eyestrain Child complains of headaches Rubs eyes Inattentive Poor reading comprehension Is tired at the end of the day Holds things very close Signs of Visual Processing Disorders Trouble learning left from right Reverses letters and numbers Mistakes words with similar beginnings Can’t recognize the same word repeated on a page Trouble learning basic math concepts of size, magnitude Poor reading comprehension Poor recall of visually presented material Trouble with spelling and sight vocabulary Sloppy writing skills Trouble copying from board to book Erases excessively Can respond orally but not in writing Seems to know material but does poorly on written tests Is your child becoming progressively more nearsighted? Yes No Are you interested in Myopia Control to prevent your child from becoming more nearsighted? Yes No PERSONAL AND MEDICAL BACKGROUND INFORMATIONPatient Name(Required) First Last Date(Required) MM slash DD slash YYYY Occupation Hobbies Name of Spouse 1. The main reason(s) for today’s visit is / are: 2. When was your last Eye Examination? Last General Physical? 3. MEDICAL HISTORY: Please list ALL …a. Medical Problems (Diabetes, High Blood Pressure, Kidney Disease, Cancer, etc.)(Required) Add Removeb. Medications that you are taking, and what you are taking them for:(Required) Add Remove4. The Optomap Retinal Examination is prescribed in our office to evaluate the health of your retina (back part of the eye). The advantages to you are: Fast (less than 1 second per eye) No blurred vision afterwards and no need for Dilation in most cases. You will be able to see the back part of your own eye, and the doctor will explain the findings. 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. The fee for this test is $45.00. This test is not covered by any medical insurance. I choose to have this test(Required) Yes No iWellness exam For patients over 40, we will be including an iWellness exam as part of your eye exam. The iWellness exam is a preventative screening test using the Optical Coherence Tomography (OCT). Its purpose is to detect potential health issues before they become serious. The high-resolution imaging assesses the health of the retina, optic nerve and other structures of the eye, as well as risk assessments for health conditions such as diabetes and hypertension. 5. The Comprehensive Examination addresses eye health and eyeglass prescriptions. 6. Contact Lens Examination: There are 3 levels; standard, complex, and custom. The fee for this service is separate from the comprehensive examination. 7. A Vision Plan examination is a routine examination for healthy eyes. Medical Insurance is for MEDICAL issues such as Diabetes, Brain Injury, Strabismus (an eye turn), Amblyopia (lazy eye). EYE or HEAD injuries, illnesses, or surgeries? Yes No Headaches? Yes No Is there a family history of any severe eye problems or health problems? Yes No Explain Do you currently wear Eyeglasses Contact Lenses Are you interested in Getting Eyeglasses today? Yes No Are you interested in Getting Contact Lenses for full time, part time, or for occasional wear, such as sports or social events? Yes No Are you interested in learning about a Non-Surgical method to correct your vision? Yes No Learning about ways to control and prevent your child from becoming more nearsighted each year? Yes No Is your child having school-related problems or difficulty reading? Yes No Are you having vision problems after LASIK or PRK? Yes No Are you having vision problems after a Brain Injury? Stroke, Crash, Fall, etc. Yes No
