tnvisiontherapy.com - Myopia History

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*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
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 TherapyLazy EyeCrossed EyeADHDNone
Learning Disabilities*

ConvergenceAutismTracking IssuesReading IssuesNone
Current/Previous Patient*
CONTACT INFORMATION
Mother/Caretaker’s Name*
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Occupation & Place of Employment*
Father/Caretaker’s Name*
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Occupation & Place of Employment*
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Your Child’s Medical History:

Please fully complete
Pediatrician*
Date of Last Visit*

MonthDayYear
Date
Optometrist Name*
Date of Last Visit*

MonthDayYear
Date
Current Medications (include vitamins/supplements)*
Is your child allergic to any medications or medical preservatives?*

YesNo
Drug Allergies*
Does the patient have a vitamin D deficiency?*

YesNo
Has the patient EVER had an allergic reaction to Atropine?*

YesNo
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: *

Rows	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*

MonthDayYear
Date
Should be Empty:

TENNESSEE VISION THERAPY

HOW DID YOU HEAR ABOUT US?

CONTACT INFORMATION

Your Child’s Medical History:

Parent History

SCREEN & LEISURE TIME

SLEEP HABITS