TENNESSEE VISION THERAPY
Please return all forms at least 48 hours prior to your appointment by fax, email or regular mail
Patient’s Full Name
Nickname
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell
Please enter a valid phone number.
Email
example@example.com
Name of School
Grade
HOW DID YOU HEAR ABOUT US?
Referred Name & Place of Business
Internet Which terms did you search?
Vision Therapy
Lazy Eye
Crossed Eye
ADHD
Learning Disabilities
Convergence
Autism
Tracking Issues
Reading Issues
Current/Previous Patient
CONTACT INFORMATION
Mother/Caretaker’s Name
Cell
Please enter a valid phone number.
Email
example@example.com
Work Phone
Please enter a valid phone number.
Occupation & Place of Employment
Father/Caretaker’s Name
Cell
Please enter a valid phone number.
Email
example@example.com
Occupation & Place of Employment
Work Phone
Please enter a valid phone number.
Your Child’s Medical History:
Please fully complete
Pediatrician
Date of Last Visit
-
Month
-
Day
Year
Date
Optometrist Name
Date of Last Visit
-
Month
-
Day
Year
Date
Current Medications (include vitamins/supplements)
Is your child allergic to any medications or medical preservatives?
Yes
No
Drug Allergies
Does the patient have a vitamin D deficiency?
Yes
No
Has the patient EVER had an allergic reaction to Atropine?
Yes
No
Does your child play sports, if so please list
At what age did the patient first start wearing eyeglasses or contact lenses?
What is your child’s usual posture when reading (for example, sitting at a desk, in bed on theirstomach, in bed on their back, etc?)
If your child is required to do a lot of reading (more than 10 minutes at once), when do theyusually do it? Morning, afternoon, or night?
Parent History
Currently wear eyeglasses or contact lenses? If yes, for what?
Any history of any eye surgery, including refractive surgery (LASIK, PRK, etc)?
Age first wore eyeglasses or contact lenses, even if part time?
Any history Retinal holes, tears, detachments or degenerative myopia?
Sibling History Questions:
NAME
Current Age
Male or
Female
Glasses or
Contacts
Started
wearing @ age
1
2
3
4
SCREEN & LEISURE TIME
Average screen time per day (TV, tablets, computers, phones, etc.)
When your child is reading on a digital device (smartphone or computer), is the backgroundblack with white characters, or white with black characters?
During a typical day, how many hours per day does the patient spend outside?
SLEEP HABITS
How many hours of sleep does the patient get each night?
What time does you/your child usually go to bed?
How many nights per week does you/your child usually go to bed at approximately the same time?
Parent Signature
Date
-
Month
-
Day
Year
Date
Submit
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