Skip to main content

Please click here to view our new COVID-19 Protocols | Telemedicine options also available here.

Located on Route 9 North in Old Bridge, NJ

732-393-8636

Request Appointment

About Us
Vision Therapy
Neuro-Optometric Rehabilitation
Ortho-K Treatment
Specialty Contact Lenses
Myopia Management
Hours & Directions

Menu

About Us
Vision Therapy
Neuro-Optometric Rehabilitation
Ortho-K Treatment
Specialty Contact Lenses
Myopia Management
Hours & Directions

Moshe-Slides-v3-6

Moshe-Slides-v3-2

Home » Contact Us » Patient Medical History Forms » Online Patient Registration Form

Online Patient Registration Form

New Patient Forms (2020)

Step 1 of 3

33%

I am filling this out for*
- Myself
- Child

CHILD EXAMINATION QUESTIONNAIRE FOR PARENTS
Today'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 & Months
Example: 9 years old and 8 months.
Brothers / Sisters Age
Grade
Brief summary of your main concerns:
School History
1. Age of entrance into kindergarten
Age of entrance into first grade
2. 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 BEHAVIOR
Please 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 Problems
Please 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 Problems
Please 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 Problems
Please 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 Disorders
Please 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:
1. Medical care for eye disease
2. Vision Therapy and Functional Vision Evaluations
3. Neuro-Optometric Rehabilitation
4. Specialty Contact Lenses (scleral, color enhancing, prosthetic, etc)
5. Orthokeratology >
6. Pediatric and children eye care and vision examinations
7. 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:
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.
- "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 Questionnaire
1. Are you interested in getting eyeglasses today?
- Yes
- No
2. Are you interested in getting contact lenses?
- Yes
- No
3. Is your child having school-related problems or difficulty reading?
- Yes
- No
4. Are you having vision problems after LASIK or PRK?
- Yes
- No
5. Are you having vision problems after Brain injury? Crash, fall, etc
- Yes
- No
6. Are you interested in learning about a Non-Surgical method to correct your vision?
- Yes
- No
7. Do you wear:
- Eyeglasses
- Contact Lenses
- Both
- Neither
8. Do you see clearly at distance, for example, driving or watching TV?
- Yes
- No
- Only if I wear my glasses.
- Only if I wear my contact lenses.
9. Do you see clearly at near, for example reading, sewing, computer?
- Yes
- No
- Only 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.

Reason?*
- School & Learning Problems
- Lazy Eye
- Vision Correction Without Surgery
- Brain Injury & Concussion
- ADD/ADHD
- Autism
- Dyslexia
- Specialty Contact Lenses
- Color Blindness
- Comprehensive Eye Exam
- Other
(You can choose more than one)
More Info?*
Preferred Date/Time*
New or Returning?*
- New patient
- Returning
Name*
First Last
Phone*
Best Time to be Reached for Confirmation*

HH :

MM
Email*
Email
This field is for validation purposes and should be left unchanged.

Hours

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:00 AM - 2:30 PM
Saturday: Closed
Sunday: Closed

Appointment times may vary so call us for available.

For directions & Info about our location

Schedule An Appointment Online

Dr. S. Moshe Roth, OD FCOVD

Meet Our Eye Doctor

Important Links

Home
Email Us
Hours & Directions
Vision Insurance
Patient Medical History Forms
Eye Care Services
Our Optometrist
Referring Physicians

Home
Email Us
Hours & Directions
Vision Insurance
Patient Medical History Forms
Eye Care Services
Our Optometrist
Referring Physicians

Quick Links

About Us
Vision Therapy
Orthokeratology
Specialty Contact Lenses
Myopia Management
Syntonic Phototherapy
Binocular Vision Dysfunction (BVD) and Vertical Heterophoria (VH)

About Us
Vision Therapy
Orthokeratology
Specialty Contact Lenses
Myopia Management
Syntonic Phototherapy
Binocular Vision Dysfunction (BVD) and Vertical Heterophoria (VH)

Ask Here, Voice Search

Family Eye Care - Located at 3111 U.S. 9, Old Bridge, NJ 08857 Phone: 732-679-2020 https://www.newjerseyeyesite.com

Powered by EyeCarePro.com
The materials and articles contained on this website are copyrighted and protected under Title 17 of the United States Code
Sitemap | Email Accessibility | Website Accessibility Policy | Login