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Home » Contact Us » Patient Forms » Student History Form Vision

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 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 SITUATION

Why 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 HISTORY

List any illnesses, seizures, accidents, surgeries, fevers, etc.

Illness/Injury

Age

Severity

Complications (if any)

List 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 HISTORY

When 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:

Name

Age

Visual Condition

Treatment

Are there any indications of hearing or speech-related problems?

Yes

No

explain

DEVELOPMENTAL HISTORY

Were 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 BEHAVIOR

Does 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 HISTORY

Kindergarten:

1 st grade:

Does your child like school?

Does your child like his/her teacher?

Your child’s school work is:

Above Average	Average	Below average	Well below average

Do 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:

HOME ENVIRONMENT

List anyone who lives at home with your child.

Name

Age

Gender

Relationship to the child

Is 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 HOBBIES

Does 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?

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Advanced Eye Center

5151 Bluebonnet Blvd
Baton Rouge, LA 70809

Phone: 225-769-6010
Email: frontdesk@advancedeyecenter.com
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 5:30 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: Closed
Saturday: Closed
Sunday: Closed

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Advanced Eye Center
5151 Bluebonnet Blvd
Baton Rouge, LA 70809
Phone: 225-769-6010
https://www.advancedeyecenter.com

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