SENSORIMOTOR Toddler/Prek

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#

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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!

Patient Information

Child’s full name

First Last

Age

Birth date

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?

Young Child History

Any history in your family of the following?

Amblyopia (Lazy Eye)

Strabismus (Eye Turn)

Retinal Problems

Other Eye Disease

Has your child been diagnosed as having:

Learning disabilities

Developmental delays

ADD or ADHD

Cerebral Palsy

Seizure disorders

Autism

Brain injury

Other

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

Have you ever received:

Occupational therapy services?

Yes

By whom? and when

Results

Speech therapy services?

Yes

By whom?

Results

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

List any other treatments or recommendations you have received regarding your child’s vision:

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

Name

Age

Visual Situation

Untitled

Yes

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

Sensorimotor Development

For each question please check “yes” or “no” and then check each of the subsequent statements, which describe your child. Your responses will probably be most accurate if you read all of the descriptions under the question before selecting “yes” or “no”. If you have additional of different descriptions, please include them under “other”.

1. Is your child particularly sensitive to touch?

Yes

Did not always find touch to be calming or pleasurable as an infant.

Yes

Is more annoyed than other children the same age by having a shampoo or face wash.

Yes

Is very picky about textures or clothing.

Yes

Is very fussy about the clothing, (e.g. dislikes collars; dislikes having to button the top button of a shirt; is uncomfortable in hats, etc.)

Yes

Is uncomfortable with long sleeves and pants; prefers as little clothing as possible.

Yes

Avoids messy activities, such as playdough, clay, mudpies, fingerpaints, and cooking.

Yes

Is excessively ticklish

Yes

Overreacts to physically painful experiences.

Yes

Underreacts to physically painful experiences.

Yes

Tends to withdraw from a group, or bump or push others in a group; is irritable in close quarters.

Yes

Other:

2. Does your child have trouble with gross motor or posture?

Yes

Tends to slump in chair or sprawl over chair and table.

Yes

Does not feel very “firm” when you lift child up or move child’s limbs to dress.

Yes

Has difficulty turning knobs or handles which require some pressure.

Yes

Fatigues easily during family outings or during physical activities.

Yes

Has a rather tight, tense grasp on objects.

Yes

Has a loose grasp on objects, such as pencils, scissors, spoon or something he/she is carrying.

Yes

Other:

3.Does your child particularly enjoy fast-moving or spinning equipment at the playground or at home, seeming to be less dizzy than the others or not dizzy at all?

Yes

Likes to swing very high and/or for a long time.

Yes

Frequently rides the playground merry-go-round when others help keep it turning.

Yes

Especially likes movement at home, bouncing on furniture, rocking chair or swiveling chair

Yes

Enjoys getting into an upside-down position (feet up, head down.)

Yes

Likes games where vision is occluded, keeping eyes closed for fun or using a blindfold.

Yes

Enjoys most of the fast and “scary” kiddy rides when at an amusement park.

Yes

Other:

4. Does your child show particular caution in approaching activities involving fast movement or movement of the body through space?

Yes

Tends to avoid swings or slides or uses them with hesitation.

Yes

Does not like riding a see-saw or going up and down an escalator.

Yes

Is cautious about heights and climbing.

Yes

Enjoys movement initiated by him/her self but not by others, especially if it’s not expected.

Yes

Dislikes trying new movement activities or has difficulty learning them

Yes

Has difficulty climbing or descending stairs or hills

Yes

Tends to get motion sickness in a car, airplane, or elevator.

Yes

Other:

5. Do you feel your child has already established a definite hand preference or dominance?

Prefers the right hand.

Yes

Prefers the left hand

Yes

Comments:

6. Can your child easily orient his/her body effectively for dressing activities, such as putting arms in sleeves, putting fingers in mittens or putting toes in socks?

Yes

Comments:

7. Does your child spontaneously engage in active physical games involving running, jumping, and use of large play equipment?

Yes

Comments:

8. Does your child spontaneously seek out activities requiring manipulation of small objects?

Yes

Comments:

9. Does your child spontaneously choose to do activities involving the use of “tools”, such as crayons, pencils, markers, scissors, etc?

Yes

Comments:

10. Have you ever had any concerns regarding your child’s speech and language skills?

Yes

Comments:

11. Have you ever had any concerns regarding your child’s hearing, either in general or in conjunction with ear infections?

Yes

Comments:

12. Is your child particularly sensitive to noise (for example puts hands over ears when others are not bothered by sounds)?

Yes

Comments:

13. Do you feel that your child has an adequate attention span for things which he/she enjoys?

Yes

Comments:

14. Do you feel that your child tends to be restless or “fidgety” during times when quiet concentration is required?

Yes

Comments:

General Behavior

Are there any behavior concerns? What causes theses concerns?

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?

Give a brief description of your child as a person:

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 Toddler/Prek

Insurance Information

Financial Policy Release of Information Privacy Practices Acknowledgement

VERY IMPORTANT! NEW PATIENTS ONLY

Patient Information

Parent(s) Information

Medical History

Young Child History

Nutritional Information

Developmental History

Visual History

Present Situation

Sensorimotor Development

General Behavior

Family and Home

Report Policies

North Royalton

Beachwood

Westlake