Child History Please Select Location* Urbandale Office West Des Moines Office Child's Full Name First Middle Last Date MM slash DD slash YYYY Parent's or Guardians Name (Mother and Father) Siblings (Include Age) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneBusiness or Cell Phone: FatherMotherWho will be responsible for this account? Name Check Cash VISA MasterCard Discover Insurance Child's Age Birthday MM slash DD slash YYYY Grade Last Visual Exam Date MM slash DD slash YYYY Most Recent Eye Doctor Were glasses prescribed? When are they worn? Age first prescribed Vision Therapy or Eye Surgery List ALL medications taken regularlyList ALL allergies to medications or the environmentHow did you hear about us? Patient Doctor Therapist/Teacher Internet/Social Media NameName PRESENT SITUATIONDescribe any indications of visual or reading Difficulty Does your child report any of the following?Headaches Yes No Sometimes When? Where? Blurred Vision Yes No Sometimes When? Where? Double Vision Yes No Sometimes When? Where? Eyes "hurt or tired" Yes No Sometimes When? Where? Eye turns In or Out Yes No Sometimes When? Where? One eye not as clear as the other Yes No Sometimes When? Where? Greater than 4 hours of screen use Yes No Sometimes When? Where? Has your child been diagnosed with Learning Disability Development Delay ADD/ADHD Autism Cerebral Palsy Dyslexia Do you and the teacher feel that the child is not working up to patential? SYMPTOM CHECKLISTName First Last Date MM slash DD slash YYYY After each symptom listed, circle the number that best describes how often you experience that particular problem. 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = AlwaysSkips lines or loses place while reading or copying 0 1 2 3 4 Omits small words 0 1 2 3 4 Substitutes words while reading or copying 0 1 2 3 4 Rereads words or lines in order to remember what was read 0 1 2 3 4 Reverse letters(b & d, p & q), numbers or words 0 1 2 3 4 Uses a finger or marker to keep place 0 1 2 3 4 Reads very slowly 0 1 2 3 4 Poor reading comprehension or it worsens over time 0 1 2 3 4 Holds books close or leans in too close to papers and screens 0 1 2 3 4 Squints, closes or covers one eye while reading 0 1 2 3 4 Poor posture or tilts head when reading or writing 0 1 2 3 4 Unusually tired, or falls asleep after completing a visual task 0 1 2 3 4 Difficulty copying from board 0 1 2 3 4 Crooked or poorly spaced writing 0 1 2 3 4 Print moves or goes in and out of focus when reading 0 1 2 3 4 Words overlap, run together or appear to jump when reading 0 1 2 3 4 Misaligns letters or numbers especially in columns 0 1 2 3 4 Clumsy, accident prone or poor coordination 0 1 2 3 4 Poor, inconsistent performance in sports 0 1 2 3 4 Loses concentration when doing close work, short attention span 0 1 2 3 4 Avoids near tasks such as reading 0 1 2 3 4 Confuses right and left directions 0 1 2 3 4 Car sickness or motion sickness 0 1 2 3 4 Burning, watery or red eyes 0 1 2 3 4 Excessive blinking or eye rubbing 0 1 2 3 4 Daydreaming 0 1 2 3 4 Sensitivity to light 0 1 2 3 4 Difficulty completing assignments in reasonable time 0 1 2 3 4 Headaches or eyes hurt while watching "3D" movies 0 1 2 3 4 Reading below grade level, finds reading a chore 0 1 2 3 4 SCHOOL HISTORYAverage School Work Above Average Average Below Average Best Subject Hardest Subject Age Started Kindergarten Grades Repeated Reason Attitude Toward School Describe any special tutoring, therapy, and/or remedial assistance (IEP,504) including when, from whom, how long and resultsDescribe any Problem Associated with School DEVELOPMENTAL HISTORYComplications During Pregnancy During/After Birth Birth Weight Untitled First Choice Second Choice Third Choice Complications of Development Check any the following which DID NOT occur at the expected time Sit Crawl Stand Walk Put Puzzles Together Say First Words Talk in Sentences Ride Bicycle Begin Handwriting Childhood Illnesses or Other Chronic Conditions (Age of diagnoses)Accidents Eye or Head Injuries Family Doctor Date of Last Physical Describe Any Surgery Other Conditions Which May Affect DevelopmentHas your child ever had a Neurological evaluation? Date/Location Psychological evaluation? Date/Location Hearing and/or Speech evaluation? Date/Location Occupational and/or Physical Therapy evaluation? Date/Location FAMILY HISTORYOTHER MEMBERS OF FAMILYMedical Problems (Diabetes, Blood Problems, Allergies, ect.)IllnessRelationshipAgeTreatments and/or Complications Visual Problems (Cataracts, Glaucoma, Amblyopia, Turning Eye, ect.) IllnessRelationshipAgeTreatments and/or Complications GIVE A BRIEF DESCRIPTION OF THIS CHILD AS A PERSON Signature
