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Hours & Location
Meet Dr. Bassiri
Advanced Services
Eye Care Services
Eye Glasses
- Designer Frames
- Eyeglass Lenses
Contact Lenses
Our Eye Clinic

Home » Patient Info » Medical History Form for Children

Medical History Form for Children

Medical History Form for Children

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

1Patient Information

2Insurance Information

3Medical History

4Ocular History

Today's Date*
MM slash DD slash YYYY
Child Name*
First Middle Initial Last
Parent Name*
First Middle Initial Last
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Address*
Address Line 2
City*
State*
Zip*
Country*
Social Security Number*
(last 4 digits)
Gender*
- Female
- Male
Phone, Cell*
Phone, Alternate
Email Address*
Preferred Language*
Race*
Ethnicity*
Communication Preference*
How were you referred to our office?*
Please Specify:
For example, if friend or family, who?

Primary Care Physician*
Date of Last Physical Exam*
MM slash DD slash YYYY
Medications
Allergies
Surgeries
Surgeries/Serious Illness
Social History
I prefer to discuss my social history information directly with my doctor*
- Yes
- No
Tobacco Use*
- Never
- Former
- Current light smoker
- Current smoker
How many packs do you smoke per day?*
How many years have you been smoking?*
Do you drink alcohol?*
- None
- Social Use
- 1-2 drink daily
- Above average use
- Alcohol dependence
Narcotic Use*
- Yes
- No
Family History
Review of Systems
Constitutional
Weight Loss*
- Yes
- No
Fever*
- Yes
- No
Dizziness*
- Yes
- No
Cancer*
- Yes
- No
Ears/Nose/Throat
Allergies/Hay Fever*
- Yes
- No
Sinus Congestion*
- Yes
- No
Dry Throat/Mouth*
- Yes
- No
Post-Nasal Drip*
- Yes
- No
Chronic Cough*
- Yes
- No
Cardiovascular
High Blood Pressure*
- Yes
- No
Elevated Cholesterol*
- Yes
- No
Heart Pain*
- Yes
- No
Vascular Disease*
- Yes
- No
Respiratory
Asthma*
- Yes
- No
Emphysema*
- Yes
- No
Chronic Bronchitis*
- Yes
- No
Sleep Apnea*
- Yes
- No
Chronic Obstructive Pulmonary Disease*
- Yes
- No
Gastrointestinal
Diarrhea*
- Yes
- No
Constipation*
- Yes
- No
Bloody Stool*
- Yes
- No
Genitourinary
Frequent Urination*
- Yes
- No
Kidney Disease*
- Yes
- No
Prostate Cancer/Disorder*
- Yes
- No
Musculoskeletal
Arthritis*
- Yes
- No
Rheumatoid Arthritis*
- Yes
- No
Muscle Pain*
- Yes
- No
Skin & Integumentary
Rashes*
- Yes
- No
Sores*
- Yes
- No
Blisters*
- Yes
- No
Growths*
- Yes
- No
Neurological
Numbness or tingling sensation*
- Yes
- No
Headaches*
- Yes
- No
Migraines*
- Yes
- No
Seizures*
- Yes
- No
Psychiatric
Anxiety*
- Yes
- No
Depression*
- Yes
- No
Bipolar*
- Yes
- No
Schizophrenia*
- Yes
- No
Endrocrine
Diabetes*
- Yes
- No
Thyroid/Other Gland*
- Yes
- No
Hematologic/Lymphatic
Anemia*
- Yes
- No
Abnormal Bleeding*
- Yes
- No
Clotting Disorder*
- Yes
- No
Allergic/Immunological
Allergic Reaction*
- Yes
- No
Recurrent Infections*
- Yes
- No
HIV/AIDS*
- Yes
- No

Date of Last Eye Exam*
- <1 year
- 1-2 years
- 5+ years ago
- 10+ years ago
- Never
Do you wear glasses?*
- Yes
- No
Do you wear contacts?*
- Yes
- No
What Brand?*
How often do you replace your lenses?*
What brand of solution do you use?*
How many hours a day do you wear contacts?*
Ocular Family History
Cataracts*
- Yes
- No
Strabismus/Eye Turn*
- Yes
- No
Glaucoma*
- Yes
- No
Diabetic Retinopathy*
- Yes
- No
Macular Degeneration*
- Yes
- No
Retinal Detachment*
- Yes
- No
Blindness*
- Yes
- No
Other*
- Yes
- No
If other, please specify:
Are you experiencing any of the following?
- Blurry Vision
- Burning
- Distorted Vision/Halos
- Double Vision
- Dryness
- Excess Tearing
- Eye Infection
- Eye Pain
- Floaters
- Headaches
- Itching
- Light Flashes
- Light Sensitivity
- Loss of Vision
- Loss of Side Vision
- Redness
- Sandy, Gritty Feeling
- Sties/Chalazion
- Tired Eyes
- Mucous Discharge
- Other
If other, please specify:
Cancellation Policy*
- A $50 fee is charged to any appointment canceled without a 48 hour notification.
Privacy Policy*
- I have read and agree to the Privacy Policy.
Phone
This field is for validation purposes and should be left unchanged.

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Fusion Eye Care
6400 Creedmoor Rd, #103
Raleigh, NC 27613
Phone: 919-648-0800
https://www.fusioneyecare.com

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