Eye Exam – Child Child Intake Form DateNameMaleFemaleAgeParentsMother's NameEmail AddressMobile phoneFather's NameEmail AddressMobile phoneStatusMarriedSeperatedDivorcedOtherLanguages Spoken at HomeEnglishOtherMajor ConcernsPlease 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 regardingNeed an eye exam because ofWhen did it start (onset)?How has it changed since it started?StableBetterWorseHow big of a problem is it (severity)?NotSlightModerateMuchExtremeHow often does it happen (frequency)minutehourdayweekmonthyearconstantconstantHow long does it last (duration)secondsminutehourdayweekmonthyearWhat 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 concernsWhen was the last eye exam (years ago)What are the visual demands on a typical day?ReadComputerDriveTVSportSafety Glasses required forHomeWorkSportOtherWhat 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)Select12345Pick a number from 1 -5 with 1 being the bestComputerSelect12345Pick a number from 1 -5 with 1 being the bestNear/Read (paper, smart phone, tablet)Select12345Pick a number from 1 -5 with 1 being the bestPlease provide contact lens information if applicableTypeSelectSoftRGPScleralOtherBrandSelectCooperAlconJohnson & JohnsonOtherPower - Right EyePower - Left EyeHow oftenEverydayPart-timeper weekper monthWear time - hours per dayPut a fresh/new contact lens on everySelectDayWeekMonthYearOtherTake out nightlySelectYesNoCareDispose when doneRub & Rinse before storageContact SolutionSelectBioTruOtherEye Health (Ocular Health)Do you have any of these signs or symptomsRed (erythema)SelectYesNoItch (purritis)SelectYesNoDrySelectYesNoWaterySelectYesNoBurnSelectYesNoDiplopiaSelectYesNoHaloesSelectYesNoFlashes of lightSelectYesNoFloatersSelectYesNoAllergiesEnvironmentalDrugEye Health history of your child and familyEye injuryChildFamilyDetailsEye SurgeryChildFamilyDetailsCataractChildFamilyDetailsGlaucomaChildFamilyDetailsMacular DegenerationChildFamilyDetailsRetinal DetachmentChildFamilyDetailsGeneral Health history of your child and familyCardio VascularChildFamilyDetailsDermatologicChildFamilyDetailsEndocrineChildFamilyDetailsEar, Nose, ThroatChildFamilyDetailsGastro-IntestinalChildFamilyDetailsHead/NeckChildFamilyDetailsMuscular/SkeletalChildFamilyDetailsNeurologicalChildFamilyDetailsRespitory (lung)ChildFamilyDetailsPsychiatricChildFamilyDetailsOtherChildFamilyDetailsWhat medications do you take?Consent *Yes, I agree with the privacy policy and terms and conditions.SignatureStart signing your signature hereYour browser does not support e-Signature field.Submit FormPlease do not fill in this field.