Honolulu Eye Clinic
Pediatric Ophthalmology/Adult Strabismus - New Patient Questionnaire
«First Name» «Last Name»
Pt #: «Id» DOB: «Date Of Birth»
History of Eye Problems:
Yes No Glasses/Contact lenses/Prisms
  Glasses
  Contact lenses
  Hard, Gas permeable, or Soft?
  Prisms
Yes
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No
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Other eye symptoms
Eye exam by specialist
Patching
Eye exercises
Eye muscle surgery
Other eye surgery
Diabetic eye disease
Other Recent Symptoms:
Yes No Symptom
  Weight loss
  Excessive fatigue
  Fever
  Earaches
  Sore throat
  Dry mouth
  Chest pain
  Rapid heart rate
  Shortness of breath
  Swelling of hands/feet
  Loss of appetite
  Vomiting
DOS: «Appointment Date» «Time»
How old is current pair?
How old is current pair?
Contact lens cleaning solutions:
How long?
Age or How Long? Yes
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Recent Eye Symptoms:
Yes No
  Crossed or wandering eye
  Excessive squinting
  Double vision
  Excessive eye rubbing
  Frequent tearing or discharge
  Blurred vision
  Light sensitivity
Other eye symptoms not mentioned above:
Age: «Current Age»
How long? Yes
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How long?
Yes
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No

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Other eye symptoms
Eye injury
Stye
Recurring “pink eye”
Cataract
Glaucoma
Other:
Age or How Long?
No
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Drooping eye lid
Tired eyes when reading
Dry or gritty sensation
Itching eyes
Red eyes
Flashing lights or floaters
Poor peripheral vision
No
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Symptom
Diarrhea/constipation
Frequent/painful urination
Blood in urine
Muscle weakness
Rash
Headaches
Dizziness
Numbness
Paralysis
Memory loss
Change in school performance
Clumsiness
How long?
Family History: Which of the patient's relatives have had any of the following?
Yes No Eye Conditions in other family members:
Which relative? (Circle or fill in.)
  Glasses before age 6
Father Mother Sister Brother
  Amblyopia (“lazy eye”)
Father Mother Sister Brother
  Patching treatment
Father Mother Sister Brother
  Strabismus (“crossed” or “wandering” eye)
Father Mother Sister Brother
  Eye muscle surgery
Father Mother Sister Brother
  Cataracts in childhood
Father Mother Sister Brother
  Glaucoma in childhood
Father Mother Sister Brother
  Blindness in childhood
Father Mother Sister Brother
  Eye disease caused by diabetes
Father Mother Sister Brother
  Macular degeneration
Father Mother Sister Brother
  Retinal detachment
Father Mother Sister Brother
  Other serious eye disease in childhood
Father Mother Sister Brother
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
How long?
Yes
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No
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Medical conditions in other family members:
Complications from anesthesia
Genetic disease (runs in family)
Heart disease
Diabetes
Yes
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No
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High blood pressure
Stroke
Cancer
Other serious illnesses in family members:
Medical History
Yes No Condition
Yes No Condition
Yes No
  Frequent ear infections
  Diabetes

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  Sinus disease
  Anemia

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  Heart disease
  Kidney disease

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  High blood pressure
  Thyroid problem

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  Asthma
  Arthritis

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Major illnesses or previous surgery not mentioned above (other than eye problems):
Medications
List any eye drops the patient is taking:
Eye drop and frequency
 NONE
Neurologic disease
Seizures or stroke
Depression
Cancer
Missing immunizations
List any medications the patient is taking:
Medication and dosage
 NONE
Birth history (Pediatric patients only): Birth weight: ____ lb, ____ oz
Yes No Condition
Please provide details
  Problems during pregnancy
Describe:
  Problems during delivery
Describe:
  Forceps delivery
  Cesarean section
  Delivered early
How many weeks?
  Baby kept in hospital due to illness
Why and how long?
Reviewed by: Dr. _______________________ Date: _________
F:/AAA/Administrative/Master & Forms/Registration forms/Peds Registration Form.doc