Children's History Form
Please select office location:
*
Westerville Office
Johnstown Office
The Solution Center
Lewis Center
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Is this the child's first complete vision examination?
Yes
No
Delivery Type:
Vaginal
C-Section
Please select any of the following options that may apply to your child's development.
Problems during pregnancy
Problems during delivery
Any fever greater than 103 degrees
Premature birth
Other
What was the age your child started walking?
What was the age your child started talking?
Please select any coordination challenges your child experiences:
Eye-hand coordination
Problem with throwing/catching a ball
Problem with handwriting
Please select any functional challenges your child experiences:
Problem recognizing colors
Problem recognizing numbers
Problem recognizing letters
Problems with letter/word reversals
Please select any of the visual history options that apply to your child:
Has had an eye patched
Has had any problems with an eye turn
Covers one eye when looking at story books
Wears eyeglasses
Wears contact lenses
Please select any therapy your child has been involved with:
Vision Therapy
Speech Therapy
Occupational Therapy
Physical Therapy
Please select any challenges your child experiences in reading and/or school:
Eye strain with reading
Eye rubbing with reading
Headaches with reading or close work
Reading comprehension problems
Skipping lines when reading
Re-reading lines
Special class for any subject
Repeated grade(s)
Pediatrician Name
Practice Name
Grade in School
School Name
Child's Favorite Subject and Grade in that Class
Child's Hardest Subject and Grade in that Class
Is your child on any medications? Please list them below.
Does your child have any allergies? Please list them below.
Is there anything else we should know?
Submit
Should be Empty: