Child History Form

WELCOME TO ENVISION EYECARE

We appreciate you choosing us for your professional eye care.
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Child's Name
Last Name*
First Name*
Middle Initial
Today's Date
Nickname
Home Address
City
State
Zip
Date of Birth
Preferred Phone
Type of Phone
Email
Race
Have we taken care of your family members? If yes, whom?
Medical Insurance
Vision Insurance
Front of Insurance Card
Back of Insurance Card
Policyholders Name
Policyholder’s Employer
What is the Reason(s) for the Visit?
Can we thank someone for referring you? Whom?
Is your child having vision problems without glasses?

Glasses

Does your child wear glasses? If no, skip to the next section.
Do they have computer glasses?
Is your child having vision problems with glasses?
Is your child interested in getting new glasses?
Do they have an anti-glare?
Do they have prescription sunglasses or changing tint?

Contact Lenses

Does your child wear contact lenses?
Do they want to try them?

Ocular History

How many hours per day does your child use a cell phone?
List all major injuries, surgeries, and/or hospitalizations

Hobbies and Activities

Child’s current grade in school
Does your child know numbers and letters?
How many hours per day on the computer?
How many hours per week spent outdoors?
What hobbies does your child enjoy?
Do these activities strain your child’s eyes?
Name of Medical Doctor
Last Medical Exam
Medications
Any Allergies?
If yes, please list.

Review of Systems - Please check all that apply or fill in the blank for those not listed.
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Any changes to your child’s Medical History since the last visit? If yes, please complete.
Constitutional
Ears, Nose, Throat
Neurological
Psychiatric
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Endocrine
Hematologic / Lymphatic
Allergic / Immunologic

Family History
List the family member(s) that has/had the following: (Ex. Mother, Grandparent, etc)

Heart Disease
High Blood Pressure
Diabetes
Cancer
Thyroid Disease
Cataract
Glaucoma
Macular Degeneration
Lazy Eye / Amblyopia
Eye Turn / Strabismus
Nystagmus
Retinal Detachment / Disease
Arthritis
Lupus
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