Online Patient Registration Form New Patient Forms (2020) Step 1 of 3 33% I am filling this out for*MyselfChild CHILD EXAMINATION QUESTIONNAIRE FOR PARENTSToday's Date Date Format: MM slash DD slash YYYY Child's Full Name* First Last Nickname, or likes to be called First Date of Birth* Date Format: MM slash DD slash YYYY Name of Father First Last Name of Mother First Last Age: Years & MonthsExample: 9 years old and 8 months.Brothers / Sisters AgeGradeBrief summary of your main concerns:School History1. Age of entrance into kindergartenAge of entrance into first grade2. Does your child like school:3. Easiest Subject(s):4. Hardest Subject(s):5. Are there any school difficulties? If so, please describe them and when they began:6. Has there been any remedial work? If yes, please give specifics:7. Has a grade ever been repeated? Is so, which?8. Has there ever been any psychological, educational, audiological or other testing performed? If yes, please give specifics:GENERAL BEHAVIORPlease select any of the following behaviors that you believe your child exhibits and 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 ProblemsPlease select any of the following behaviors that you believe your child exhibits and any problem that seems to occur often. 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 Focusing ProblemsPlease select any of the following behaviors that you believe your child exhibits and any problem that seems to occur often. 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 Signs of Tracking ProblemsPlease select any of the following behaviors that you believe your child exhibits and any problem that seems to occur often. Loses place often Must use finger or guide to keep place Skips lines and words often Poor reading comprehension Short attention span Signs of Visual Processing DisordersPlease select any of the following behaviors that you believe your child exhibits and any problem that seems to occur often. 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 We provides Comprehensive Eye Examinations, Eyeglasses, and Conventional Contact lenses.In addition, we provide the following additional services: Medical care for eye disease Vision Therapy and Functional Vision Evaluations Neuro-Optometric Rehabilitation Specialty Contact Lenses (scleral, color enhancing, prosthetic, etc) Orthokeratology > Pediatric and children eye care and vision examinations Myopia Control OPTOMAP RETINAL EXAM: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: Fast (less than 1 second per eye). No blurred vision afterwards. You will 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 and the fee for this test is $39.00. This test is not covered by any medical insurance. "I decline the benefits of the optomap retinal exam and hold this office harmless if a medical retinal problem exists but was not identified Contact Lens Examination:There are 3 levels; standard, complex, and custom. The fee for this service is separate from the comprehensive examination. I have read the terms about the contact lens exam & contact lens assessment. Patient's Name* First Last Brief Questionnaire1. Are you interested in getting eyeglasses today?YesNo2. Are you interested in getting contact lenses?YesNo3. Is your child having school-related problems or difficulty reading?YesNo4. Are you having vision problems after LASIK or PRK?YesNo5. Are you having vision problems after Brain injury? Crash, fall, etcYesNo6. Are you interested in learning about a Non-Surgical method to correct your vision?YesNo7. Do you wear:EyeglassesContact LensesBothNeither8. Do you see clearly at distance, for example, driving or watching TV?YesNoOnly if I wear my glasses.Only if I wear my contact lenses.9. Do you see clearly at near, for example reading, sewing, computer?YesNoOnly if I wear my glasses.Only if I wear my contact lenses.10. Do your eyes: Burn Itch Feel Dry Have Discharge Tear or Water Excessively 11. Do your eyes feel: Painful Achy Irritated as though there is something in your eyes 12. Do you ever see: Double Floaters Flashes of Light Sudden Blurred or Reduced Vision 13. Are you bothered by: Double Floaters Flashes of Light Sudden Blurred or Reduced Vision 14. Occupation - what type of work do you do?15. At work, do you: Sit Stand Work above eye level Use computer extensively 16. Hobbies - What types of things do you like to do?Example: Near work such as reading, crosswords, cards, crafts.17. What sports are you involved in?Example: Basketball, Golf, Swimming, Tennis, Racquetball, etc.