InfantSee Medical History Form

InfantSee Medical History Form
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Gender:

MaleFemale
Race:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Occupation:
How did you learn about our program?
Have you ever noticed any of the following happening with your baby's eyes? (please check all that apply):

Eye turn inEye turn outEyes wateringEyes redSwelling around the eyesWhite appearance in pupil
Please explain any eye concerns noted by observing child:
Please list the length of your pregnancy in weeks:
Please list any complications during pregnancy:
Child's Birth Weight:
Mom's age at time of birth:
Father's age at time of birth:
Please list any complications during delivery:
Was oxygen used?

YesNo
Child's Doctor:
Last exam date:
Are immunizations up to date?

YesNoUnsure
Does your baby have any known food or drug allergies?

YesNo
If your baby does have any known food or drug allergies, please list them below:
Please list all medications taken regularly:
Please list any developmental delays:
Check all of the following that your baby can do at this time:

Roll overSitCrawlStandWalk
Has your baby ever had a high fever?

YesNo
If your baby has had a high fever, please list their temperature at that time:
Please list any childhood illnesses your child has had:
Please list any accidents, eye, or head injuries and age they occurred:
Please list any other conditions we should know about:
Please select any of the following eye conditions that someone in your family has had:

Lazy eye (amblyopia)Eye turn (strabismus)Eye tumor
Please list any family members with a history or eye or medical problems. List the relation and type of problem:
I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of my child's eyes and vision.

I understand that the InfantSee vision assessment is without charge. If further services or treatments are recommended, I may choose any eye care professional to provide those services.
Parent/Guardian Signature:

Clear
Today's Date:

MonthDayYear
Date
Should be Empty: