WEST MICHIGAN EYECARE ASSOCIATES, Pediatric Health History
Patient (full legal name): _______________________________ Date of birth: ________ Gender: ____
Parent/guardian name: ___________________________ Preferred phone: ________________________
Address (street/city/state/zip)____________________________________________________________
Email address:____________________________________
Today’s Date ________________
(email used primarily for appointment reminders)
Ethnicity (please select one): ___ Caucasian
___ Middle Eastern
___ Asian
___ African American
___Hispanic or Latino
___ Hawaiian/Pacific Islander ___Other ____________
Race (please select one): ___ White ___ Black or African American ___ Hawiian/Pacific Islander
___ Am. Indian/Alaska native
___Asian
___ Other ___________________
Ocular History & Complaint (s):
Previous Eye Exam:
yes __ no __
Eye Injuries:
yes __ no __
Eye Surgeries:
yes __ no __
Eye Infections:
yes __ no __
Eye Disease:
yes __ no __
Eye Glasses:
yes __ no __
Contact Lenses:
yes __ no __
Eye Drops:
yes __ no __
Patching:
yes __ no __
Vision Therapy:
yes __ no __
where/when? __________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
describe?______________________________________
Reason for Today’s Visit: (tearing, redness, double vision, eye turn, blurry vision, head-aches, failed vision
screening at school, academic difficulty, etc…)
Birth History:
Full term __ Premature __ Born at _____ (weeks)
Birth weight: __________
Complications: yes__ no__
What? _________________________________________________________
Developmental Delays: yes___ no___
Explain: __________________________________________________________________________________
Family History:
Blindness:
Glaucoma:
Strabismus (eye turn):
Amblyopia (lazy eye):
Color vision defect:
Diabetes:
Heart Disease:
Hypertension:
Learning Disability:
yes__
yes__
yes__
yes__
yes__
yes__
yes__
yes__
yes__
no__
no__
no__
no__
no__
no__
no__
no__
no__
relationship______________________________
relationship______________________________
relationship______________________________
relationship______________________________
relationship______________________________
relationship______________________________
relationship______________________________
relationship______________________________
relationship______________________________
Turn Over
Medical History:
Name/Office Pediatrician or Physician:___________________________________________________________
Address:___________________________________________________________________________________
Date of last visit:____________
Height:__________
Weight:__________
Systemic conditions:
Describe:
Constitutional (fever, weight changes)
yes__ no__
__________________
Ears, Nose, Mouth, Throat
yes__ no__
__________________
(sinus, cough, ear infections, tonsillitis)
Respiratory (asthma, shortness of breathe)
yes__ no__
__________________
Cardiovascular (blood pressure, heart)
yes__ no__
__________________
Gastrointestinal
yes__ no__
__________________
(diarrhea, constipation, reflux disease)
Genitourinary (genitals, kidney, bladder)
yes__ no__
__________________
Muscles, Bones, Joints (arthritis, pain)
yes__ no__
__________________
Endocrine (diabetes, thyroid, other glands)
yes__ no__
__________________
Psychological (anxiety, depression)
yes__ no__
__________________
Blood/Lymph (anemia, cholesterol, cancer)
yes__ no__
__________________
Allergic/Immunologic (lupus, hay fever)
yes__ no__
__________________
Skin (rashes, measles, chicken pox)
yes__ no__
__________________
Neurological
yes__ no__
__________________
(headaches, head trauma, MS, CP, seizures)
Hospitalizations:
Medications:
Medications Allergy:
Immunized:
yes__
yes__
yes__
yes__
no__
no__
no__
no__
describe _______________________________________________
list ___________________________________________________
to what?________________________________________________
Social History:
Family setting: Brothers- #__; age (s)__________________
Sisters- #__; age (s)__________________
Parents: mother’s occupation ____________________________________
father’s occupation ____________________________________
marital status __________________________________________
Hobbies/Recreational Activities of patient: ____________________________________________________
School Name: ___________________________________________
Current grade: ________________
Academic: (please skip if not pertaining to your child)
Please check the items that pertain to your child’s school difficulties:
Following multi-step, spoken directions ___
Paying attention ___
Disorganized paper work ___
Copying from board ___
Remembering Facts (spelling words/number facts) ___
Staying Focused ___
Working Independently ___
Penmanship ___
Completing work on time ___
Reversals ___
Reading (decoding) ___ (comprehension) ___
Spelling ___
Arithmetic ___
How did you hear about our office: _________________________________________
Thank you for trusting your precious gift of sight to us – please let us know if there is anything we can do to make
your visit with us more enjoyable.
Thank you.