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. 1 Patient Information2 Insurance Information3 Medical History4 Ocular History Today's Date* Date Format: MM slash DD slash YYYY Child Name* First Middle Initial Last Parent Name* First Middle Initial Last Preferred NameDate of Birth* Date Format: MM slash DD slash YYYY Address*Address Line 2City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweSocial Security Number*(last 4 digits)Gender*FemaleMalePhone, Cell*Phone, AlternateEmail Address*Preferred Language*Please SelectEnglishSpanishFrenchJapaneseDecline to specifyRace*Please SelectAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhiteDecline to specifyEthnicity*Please SelectDecline to specifyHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or LatinoCommunication Preference*Please SelectTelephoneEmailTextMailOtherHow were you referred to our office?*Please SelectFriend or FamilyFamily DoctorOpthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherPlease Specify:For example, if friend or family, who? Responsible Party*ParentGuardianOtherName* First MIddle Initial Last Address*Address Line 2City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCell Phone*Alternate PhoneEmail* DOB* Date Format: MM slash DD slash YYYY Social Security Number(last 4 digits)Medical Insurance*YesNoInsurance Company Name*Relationship to Policy Holder*Please SelectSelfParentOtherName of Policy Holder* First Last Policy Holders Phone Number*Subscriber ID #*DOB of Policy Holder* Date Format: MM slash DD slash YYYY EmployerSubscriber #Effective Date Date Format: MM slash DD slash YYYY Vision Plan*YesNoInsurance Company Name*Relationship to Policy Holder*Please SelectSelfSpouseChildOtherName of Policy Holder* First Last Policy Holders Phone Number*Subscriber ID #*DOB of Policy Holder* Date Format: MM slash DD slash YYYY EmployerGroup #Effective Date Date Format: MM slash DD slash YYYY Dental Plan*YesNoInsurance Company Name*Relationship to Policy Holder*Please SelectSelfSpouseChildOtherName of Policy Holder* First Last Policy Holders Phone Number*Subscriber ID #*DOB of Policy Holder* Date Format: MM slash DD slash YYYY EmployerGroup #Effective Date Date Format: MM slash DD slash YYYY Primary Care Physician*Date of Last Physical Exam* Date Format: MM slash DD slash YYYY Medications Allergies Surgeries Surgeries/Serious Illness Social HistoryI prefer to discuss my social history information directly with my doctor*YesNoTobacco Use*NeverFormerCurrent light smokerCurrent smokerHow many packs do you smoke per day?*Please SelectLess than 11234More than 4How many years have you been smoking?*Please Select1234567891011121314151617181920More than 20Do you drink alcohol?*NoneSocial Use1-2 drink dailyAbove average useAlcohol dependenceNarcotic Use*YesNoFamily History Review of SystemsConstitutionalWeight Loss*YesNoFever*YesNoDizziness*YesNoCancer*YesNoEars/Nose/ThroatAllergies/Hay Fever*YesNoSinus Congestion*YesNoDry Throat/Mouth*YesNoPost-Nasal Drip*YesNoChronic Cough*YesNoCardiovascularHigh Blood Pressure*YesNoElevated Cholesterol*YesNoHeart Pain*YesNoVascular Disease*YesNoRespiratoryAsthma*YesNoEmphysema*YesNoChronic Bronchitis*YesNoSleep Apnea*YesNoChronic Obstructive Pulmonary Disease*YesNoGastrointestinalDiarrhea*YesNoConstipation*YesNoBloody Stool*YesNoGenitourinaryFrequent Urination*YesNoKidney Disease*YesNoProstate Cancer/Disorder*YesNoMusculoskeletalArthritis*YesNoRheumatoid Arthritis*YesNoMuscle Pain*YesNoSkin & IntegumentaryRashes*YesNoSores*YesNoBlisters*YesNoGrowths*YesNoNeurologicalNumbness or tingling sensation*YesNoHeadaches*YesNoMigraines*YesNoSeizures*YesNoPsychiatricAnxiety*YesNoDepression*YesNoBipolar*YesNoSchizophrenia*YesNoEndrocrineDiabetes*YesNoThyroid/Other Gland*YesNoHematologic/LymphaticAnemia*YesNoAbnormal Bleeding*YesNoClotting Disorder*YesNoAllergic/ImmunologicalAllergic Reaction*YesNoRecurrent Infections*YesNoHIV/AIDS*YesNo Date of Last Eye Exam*<1 year1-2 years5+ years ago10+ years agoNeverDo you wear glasses?*YesNoDo you wear contacts?*YesNoWhat 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 HistoryCataracts*YesNoStrabismus/Eye Turn*YesNoGlaucoma*YesNoDiabetic Retinopathy*YesNoMacular Degeneration*YesNoRetinal Detachment*YesNoBlindness*YesNoOther*YesNoIf 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. NameThis field is for validation purposes and should be left unchanged.
