Student History Form Vision Patient’s Name:(Required) First Last Goes by:(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:(Required)Child’s age:(Required) Date of Birth:(Required) MM slash DD slash YYYY (Required) Female Male Mother’s Name: Father’s Name: Guardians: Child Resides With: Mother’s Occupation: Cell Phone:Work Phone:Email Address: Father’s Occupation: Cell Phone:Work Phone:Email Address: School Name: School Address: Street Address Address Line 2 City State / Province / Region Teacher’s Name: First Last Child’s grade in school: How did you hear about our office? PRESENT SITUATIONWhy do you wish to have your child evaluated? List any complaints your child makes concerning his/her vision: At what age did the problem begin? Under what circumstances? Has the problem become better or worse? Explain. Does anyone else in the family have a similar problem? Has there been any previous treatment? Does your child feel that he/she has a problem? Yes No what is the child’s attitude towards the problem? MEDICAL HISTORYList any illnesses, seizures, accidents, surgeries, fevers, etc.Illness/InjuryAgeSeverityComplications (if any) Add RemoveList any prescription or over-the-counter medications being taken, dosage, reason Health at the present time: Excellent Good Fair Poor Does your child suffer from any chronic problems (asthma, colds, allergies, ear infections)? VISUAL HISTORYWhen was your child’s last eye exam? Clinic Name: Clinic Address Street Address Address Line 2 City State / Province / Region Were glasses recommended or prescribed? Were treatment recommendations made? Yes No explain. Was the treatment plan followed (if applicable)? Was the treatment plan effective (if applicable)? Has Vision Therapy ever been recommended? Yes No has the program been completed? List any family members who have had vision treatment:NameAgeVisual ConditionTreatment Add RemoveAre there any indications of hearing or speech-related problems? Yes No explain DEVELOPMENTAL HISTORYWere there any complications during pregnancy? Yes No explain. List any medications taken during pregnancy. Natural or C-Section: Length of pregnancy: Were there any complications before, during, or after delivery? Yes No explain. Did your child crawl with stomach on floor? Yes No at what age? Did your child crawl on hands and knees? Yes No at what age? Was there anything unusual about your child’s crawling or early motor development? Yes No explain. At what age did your child walk? Does your child require arm or leg braces for walking? Which hand does your child use for:eating? Writing? Throwing? Has he/she always used the same hand? Was any guidance given on which hand to use? Which foot does he/she use for:kicking? Hopping? At what age did your child speak his/her first words? Was early speech clear to others? Is your child’s speech clear now? GENERAL BEHAVIORDoes your child actively participate in play, sports, or athletics Yes No which ones? Does your child enjoy music? Can your child carry a tune? Can your child keep rhythm? Are there any behavior problems? Yes No explain. What causes these problems? EDUCATIONAL HISTORYKindergarten: 1 st grade: Does your child like school? Does your child like his/her teacher? Your child’s school work is:Above AverageAverageBelow averageWell below averageDo you feel that your child is working up to his/her potential? Describe any school difficulties. List possible reasons you have for these difficulties.What subjects are easy for your child? What subjects are difficult for your child? Has a grade been repeated? Yes No which grade? Does your child attend special needs classes? Yes No explain Has attendance been regular? Yes No explain Does your child like to read? Does your child read voluntarily? Yes No what? Does your child prefer to be read to rather than reading on his/her own? Has your child ever been classified ADD, ADHD, LD, dyslexic or any other diagnosis? Yes No which one(s)? List any psychological or educational tests performed: Add RemoveHOME ENVIRONMENTList anyone who lives at home with your child.NameAgeGenderRelationship to the child Add RemoveIs there any additional information that we should know? (frequent moving, separation, divorce, remarriage, death, etc.) List previous nursery or other group experiences (Sunday school, camp, daycare, etc.) INTERESTS AND HOBBIESDoes your child have any special abilities? (art, music, etc.) What activities does your child find most rewarding or enjoy the most? Give a brief description of your child’s personality. Is there anything else you would like us to know? CAPTCHA