School Age Child History

Date

Patient Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mobile

home

work

Employer (or School)

Occupation (or Grade)

Date of birth

Age

Sex:

Marital Status:

What are your major concerns (and or) needs that you would like addressed today?

Any problems with your present contact lenses or glasses?

How will you settle your account today?

Cash

Check

Credit Card (MasterCard/Visa/Discover/Amex)

Care credit

Insurance Information

Medical Insurance co.

Subscriber Name

First Last

Relationship to Patient

ID#

Group#

This field is hidden when viewing the form

ID#

This field is hidden when viewing the form

Group#

Subscriber Birth Date

Subscriber Employer

Financial Policy Release of Information Privacy Practices Acknowledgement

The Vision Development Team extends the courtesy of filling out a medical insurance claim form for you to submit to your insurance company for reimbursement to you.
I understand that I will be required to pay for services at the time rendered.
I authorize Alexandar Andrich, OD, FCOVD to release any information required by my insurance company.
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Signature

Date

(Guardian signature required if patient is under 18)

VERY IMPORTANT! NEW PATIENTS ONLY

Who may we thank for referring you to our office?

Name

First Last

How did you choose our office for your needs?

Please silence cell phones prior to entering the Doctor’s exam room Thank you!

General Information

Child’s full name

First Last

Age

Birth date

School name:

School Address:

Street Address Country

Grade:

Teacher's Name

First Last

Principal's Name:

First Last

Is your child especially afraid of doctors?

Yes

Parent(s) Information

Full Name:

First Last

Relationship:

Home Address Same as patient address on Welcome Form

Yes

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone:

Occupation

Employer

Work Phone

Full Name:

First Last

Relationship:

Home Address Same as patient address on Welcome Form:

Yes

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone:

Occupation

Employer

Work Phone

Medical History

Most recent medical examination:

Doctor’s name:

First Last

Date

Results:

Medications currently using?

Yes

For what condition?

Drug allergies

School Age Child History

Have you been diagnosed as having :

List illnesses, bad falls, head injuries, high fever, ear infections, etc. (include complications and ages)

Is your child generally healthy?

Are there any chronic problems like asthma, hay fever, allergies?

Yes

please list

Has a neurological evaluation been performed?

Yes

By whom?

Results

Has a psychological evaluation been performed?

Yes

By whom?

Results

Have you ever received:

Occupational therapy services?

Yes

By whom? and when

Results

Physical therapy services?

Yes

By whom?

Results

Speech therapy services?

Yes

By whom?

Results

Auditory Training?

Yes

Other therapy?

Yes

Describe

Nutritional Information

Current Diet:

Excellent

Good

Fair

Poor

Does your child crave sweets?

Is your child

Moderately active

Extremely active

Are there periods of high energy?

Yes

Low energy?

Yes

Developmental History

Full term pregnancy?

Yes

Normal Birth?

Yes

Birth weight?

Any complications before, during, after or immediately following delivery?

Did your child crawl (stomach on floor)?

Yes

Age:

Did your child creep (stomach off floor)?

Yes

Age:

Did your child move on all fours?

Yes

Age:

describe

At what age did your child walk?

Was child active?

Yes

Speech:

First words at age

Was early speech clear to others?

Yes

Is it clear now?

Yes

Any history of crossing eyes?

Yes

What age first noticed

Any family history of crossing eyes?

Yes

Who?

Visual History

Previous eye examination:

Doctor’s name:

First Last

Date

Reason for examination

Results

Were glasses prescribed?

Yes

Are they worn?

Yes

Full-time

Part-time

Comments

Are eye exams done yearly?

Yes

Members of the family who have had visual attention and why:

Name

Age

Visual Situation

Present Situation

Is there any concern from any other professional that some visual dysfunction may be present?

Yes

Describe

Does your child report any of the following:

Headaches

Yes

When?

Blurred vision

Yes

When?

Double vision

Yes

When?

Eyes “hurt or tired”

Yes

When?

List any other complaints that your child makes concerning his/her vision

Have you ever noticed the following:

Eyes frequently reddened

Yes

When?

Frequent eye rubbing

Yes

When?

Frequent blinking

Yes

When?

Closing or covering one eye

Yes

When?

Head close to paper when reading or writing

Yes

Tilting head when reading

Yes

Tilting head when writing

Yes

Confuses letters or words

Yes

Reversing letters or words

Yes

Skip, reread or omit words

Yes

Vocalizing when reading silently

Yes

Reading slowly

Yes

Using a finger as a marker

Yes

Poor reading comprehension

Yes

Writes or prints poorly

Yes

Tires easily

Yes

Avoid near tasks

Yes

Short attention span

Yes

Poor motor coordination

Yes

Difficulty catching/hitting a ball

Yes

Television viewing:

How much

How often

Viewing distance

Average amount of sleep per night

School

Age at entrance to kindergarten

Does child like school?

Yes

Teacher?

Yes

School work is:

Above Average

Average

Below Average

Do you feel he/she is working up to potential?

Does teacher feel he/she is working up to potential?

What school subjects come easy for child?

Does child like to read?

Yes

Voluntarily?

Yes

What?

Specifically describe any school difficulties:

Has a grade been repeated?

Yes

Which?

Has he/she changed schools often?

Yes

When?

Does he/she seem to be under tension or extreme pressure when doing schoolwork?

Has he/she had any special tutoring and/or remedial assistance?

Yes

When?

From whom?

Where?

How long?

Results

How well developed is his/her spoken vocabulary?

What is the child’s attitude toward reading, school, his/her teacher, other youngsters?

General Behavior

Are there any behavior problems?

Yes

School

Home

What causes these problems?

Child’s reaction to fatigue:

None

Sad

Irritable

Other

Child’s reaction to tension?

None

Nail biting

Thumb sucking

Other

Does he/she say and/or do things impulsively?

Yes

Is your child in constant motion?

Yes

Can your child sit still for long periods?

Yes

Family and Home

Please indicate which adults he/she lives with:

Siblings:

Names:

Ages:

If applicable, please describe your child’s custody agreement:

Has he/she ever been through a traumatic family situation? (Such as divorce, parental loss, separation)

Yes

What age was he/she?

Does he/she seem to have adjusted?

Is family life stable at this time?

Yes

How does he/she get along with parents?

Siblings?

Classmates at school?

Playmates at home?

Did anyone in father’s family have a learning problem?

Yes

Who?

Did mother or anyone in mother’s family have a learning problem?

Yes

Who?

Do any, or did any of the other children in the family have learning problems?

Yes

Who?

To what extent?

Give a brief description of your child as a person:

Additional comments/concerns that you would like the doctor to be aware of:

Report Policies

Would you like copies of any reports?

yes

Would you like copies sent anywhere?

yes

Name

Address

Please sign below to give us permission to release information about your child to the above sources.

Signature

Date

SENSORIMOTOR :School Age k-12 Patient History

School Age Child History

Insurance Information

Financial Policy Release of Information Privacy Practices Acknowledgement

VERY IMPORTANT! NEW PATIENTS ONLY

General Information

Parent(s) Information

Medical History

School Age Child History

Nutritional Information

Developmental History

Visual History

Present Situation

School

General Behavior

Family and Home

Report Policies

North Royalton

Beachwood

Westlake