Pediatric Ophthalmology and Strabismus: New patient information

Pediatric Ophthalmology and Strabismus

New patient information
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Patient's Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Pediatrician
Reason for today's eye exam (Note: "check up" or "routine" exams are not covered by insurance):
Previous eye problems or surgeries:
General medical problems:
Previous surgeries:
Current medications:
Allergies to medications or latex:
Eye problems that run in the family:
Birth History
Born at ______ (weeks):
Birthweight:
Any problems with pregnancy or delivery?
Any developmental issues (such as fine motor delay, ADHD, learning disabilities)?
School:
Grade
Performing grade level schoolwork?
Anything else we should be aware of ?
Should be Empty:

Pediatric Ophthalmology and Strabismus