(905) 338-2020

patientcare@oakvillecentreforvision.com

506 Kerr Street, Oakville, ON L6K 3C5

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Child Intake Form

Date

Name

MaleFemale

Age

Parents

Mother's Name

Email Address

Mobile phone

Father's Name

Email Address

Mobile phone

StatusMarriedSeperatedDivorcedOther

Languages Spoken at HomeEnglishOther

Major Concerns

Please list your main concern(s) and/or main problems(s) your child is havingNeed an eye examNeed an eye exam for glasses, contacts or otherNeed a second opinion regarding

Need an eye exam because of

When did it start (onset)?

How has it changed since it started?StableBetterWorse

How big of a problem is it (severity)?NotSlightModerateMuchExtreme

How often does it happen (frequency)

minute

hour

day

week

month

year

constant

How long does it last (duration)

seconds

minute

hour

day

week

month

year

What seems to make it better?

What seems to make it worse?

What are other things going along with it (associated symptoms)?

Please indicate any additional information that you feel may be helpful or other concerns

When was the last eye exam (years ago)

What are the visual demands on a typical day?

Read

Computer

Drive

TV

Sport

Safety Glasses required forHomeWorkSportOther

What eye optical correction do you use for these visual tasks?

GlassesFar Away (TV or Driving)ComputerNear/Read (paper, smart phone, tablet)

Contact LensesFar Away (TV or Driving)ComputerNear/Read (paper, smart phone, tablet)

No optical correctionFar Away (TV or Driving)ComputerNear/Read (paper, smart phone, tablet)

Rate your clear comfortable vision for these visual tasks?

Far Away ( TV or Driving)Pick a number from 1 -5 with 1 being the best

ComputerPick a number from 1 -5 with 1 being the best

Near/Read (paper, smart phone, tablet)Pick a number from 1 -5 with 1 being the best

Please provide contact lens information if applicable

Type

Brand

Power - Right Eye

Power - Left Eye

How often

Everyday

Part-time

per week

per month

Wear time - hours per day

Put a fresh/new contact lens on every

Take out nightly

CareDispose when doneRub & Rinse before storage

Contact Solution

Eye Health (Ocular Health)

Do you have any of these signs or symptoms

Red (erythema)

Itch (purritis)

Dry

Watery

Burn

Diplopia

Haloes

Flashes of light

Floaters

AllergiesEnvironmentalDrug

Eye Health history of your child and family

Eye injuryChildFamily

Details

Eye SurgeryChildFamily

Details

CataractChildFamily

Details

GlaucomaChildFamily

Details

Macular DegenerationChildFamily

Details

Retinal DetachmentChildFamily

Details

General Health history of your child and family

Cardio VascularChildFamily

Details

DermatologicChildFamily

Details

EndocrineChildFamily

Details

Ear, Nose, ThroatChildFamily

Details

Gastro-IntestinalChildFamily

Details

Head/NeckChildFamily

Details

Muscular/SkeletalChildFamily

Details

NeurologicalChildFamily

Details

Respitory (lung)ChildFamily

Details

PsychiatricChildFamily

Details

OtherChildFamily

Details

What medications do you take?

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Oakville Centre for Vision provides friendly, professional services with excellence in eye care and quality products. Dr. Gall cares for you, your NeuroVision and your aspirational visually-fit outcomes.

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Contact

506 Kerr Street, Oakville, ON L6K 3C5
(905) 338-2020
(905) 338-9192
PatientCare@OakvilleCentreForVision.com

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