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Hi there, please fill out our Children's History Intake Form
37
Questions
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HIPAA
Compliance
1
Todays date
*
This field is required.
-
Date
Day
Month
Year
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2
Child's Name
*
This field is required.
Please enter your child's full name
First Name
Last Name
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3
Child's Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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4
Please locate your child's OHIP health card
Please note the health number and two letter version code
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5
OHIP Health Number
*
This field is required.
Health Number
Version Code
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6
Parent's Name
*
This field is required.
Please enter your full name
Prefix
First Name
Last Name
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7
Parent's Contact Phone
*
This field is required.
Please enter your preferred phone number
Please Select
Cell phone
Home phone
Work phone
Please Select
Please Select
Cell phone
Home phone
Work phone
Type of number
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8
Parent's E-mail
Please provide your e-mail address
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9
Address
*
This field is required.
Please enter your address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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10
Who is your child's family doctor?
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11
What is the purpose of your eye examination?
*
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What is the purpose of your visit?
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12
Date of your child's last eye exam? (leave blank if first exam)
-
Date
Month
Day
Year
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13
Has your child ever been diagnosed with an eye disease?
*
This field is required.
No
Yes
Unsure
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14
Please describe any diagnoses your child has received in the past.
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15
Has your child ever had any eye surgery, eye infections or eye injuries?
*
This field is required.
No
Yes
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16
Please describe any eye surgeries, injuries or infections that your child has had in the past.
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17
Has your ever had to complete any visual training or patching due to a lazy or cross eye?
No
Yes
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18
Has your child had normal development? Were milestones reached on time?
*
This field is required.
Yes
No
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19
Please describe any delays in development
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20
How well is your child seeing? Is your child experiencing any of the following?
Please check all that apply
blurred far vision
blurred near vision
double vision
trouble reading
poor night vision
Other
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21
Are there any concerns with your child's school performance?
Please check all that apply
falling behind in school
losing place when reading
letter reversals
does not like to read
becomes sleepy when reading
Other
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22
Is your child experiencing any of the following?
Please check all that apply
flashes of light
sensitivity to light
headaches
eye strain
Other
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23
Is your child experiencing any of the following?
Please check all that apply
soreness
itching
burning eyes
watering eyes
dry eyes
tired eyes
grittiness in eyes
redness
Other
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24
Does your child wear vision correction or eye protection (eyeglasses, safety glasses, magnifiers, sunglasses)
No
Yes
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25
What type of vision correction does your child have currently?
eyeglasses
contact lenses
safety glasses
sunglasses
magnifiers
Other
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26
How many hours does your child spend using a computer / tablet / smartphone?
0-2 hours / day
3-4 hours / day
more than 5 hours / day
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27
Does your child wear contact lenses or have they worn them in the past?
No
Yes
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28
Please check the health conditions that apply to your child or a relative by blood
Child
Sibling
Mother / Mother's side
Father / Father's side
Asthma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Cancer
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Cardiac Disease
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Diabetes
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Asthma
Cancer
Cardiac Disease
Diabetes
Child
Row 0, Column 0
Sibling
Row 0, Column 1
Mother / Mother's side
Row 0, Column 2
Father / Father's side
Row 0, Column 3
Child
Row 1, Column 0
Sibling
Row 1, Column 1
Mother / Mother's side
Row 1, Column 2
Father / Father's side
Row 1, Column 3
Child
Row 2, Column 0
Sibling
Row 2, Column 1
Mother / Mother's side
Row 2, Column 2
Father / Father's side
Row 2, Column 3
Child
Row 3, Column 0
Sibling
Row 3, Column 1
Mother / Mother's side
Row 3, Column 2
Father / Father's side
Row 3, Column 3
1
of 4
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29
Does your child have any other health conditions not listed above?
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30
Please list all of the medications, vitamins, supplements, and eye drops that your child takes
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31
Does your child have any allergies or sensitvities (drug, environmental, food) ?
*
This field is required.
No
Yes
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32
Please list all of your child's allergies or sensitivities (drug, environmental and food)
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33
Please check the eye conditions that apply to your child or a relative by blood
Child
Sibling
Mother/Mother's side
Father/Father's side
Glaucoma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Cataract
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Macular degeneration
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Lazy or crossed eyes
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Retinal detachment
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Blindness
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Glaucoma
Cataract
Macular degeneration
Lazy or crossed eyes
Retinal detachment
Blindness
Child
Row 0, Column 0
Sibling
Row 0, Column 1
Mother/Mother's side
Row 0, Column 2
Father/Father's side
Row 0, Column 3
Child
Row 1, Column 0
Sibling
Row 1, Column 1
Mother/Mother's side
Row 1, Column 2
Father/Father's side
Row 1, Column 3
Child
Row 2, Column 0
Sibling
Row 2, Column 1
Mother/Mother's side
Row 2, Column 2
Father/Father's side
Row 2, Column 3
Child
Row 3, Column 0
Sibling
Row 3, Column 1
Mother/Mother's side
Row 3, Column 2
Father/Father's side
Row 3, Column 3
Child
Row 4, Column 0
Sibling
Row 4, Column 1
Mother/Mother's side
Row 4, Column 2
Father/Father's side
Row 4, Column 3
Child
Row 5, Column 0
Sibling
Row 5, Column 1
Mother/Mother's side
Row 5, Column 2
Father/Father's side
Row 5, Column 3
1
of 6
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34
Does your child or does a family member have an eye conditions not listed above?
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35
Do you have any concerns that we need to be aware of?
Describe any allergies or sensitivities that you may have.
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36
Please review your answers and then enter your initials
*
This field is required.
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37
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38
Privacy Policy
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