Child History Please Select Location*Urbandale OfficeWest Des Moines OfficeChild's Full Name First Middle Last Date Date Format: 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? NameCheckCashVISAMasterCardDiscoverInsuranceChild's AgeBirthday Date Format: MM slash DD slash YYYY GradeLast Visual Exam Date Date Format: MM slash DD slash YYYY Most Recent Eye DoctorWere glasses prescribed?When are they worn?Age first prescribedVision Therapy or Eye SurgeryList ALL medications taken regularlyList ALL allergies to medications or the environmentHow did you hear about us? Patient Doctor Therapist/Teacher Internet/Social Media NamePRESENT SITUATIONDescribe any indications of visual or reading DifficultyDoes 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 DisabilityDevelopment DelayADD/ADHDAutismCerebral PalsyDyslexiaDo you and the teacher feel that the child is not working up to patential?SYMPTOM CHECKLISTName First Last Date Date Format: 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 copying01234Omits small words01234Substitutes words while reading or copying01234Rereads words or lines in order to remember what was read01234Reverse letters(b & d, p & q), numbers or words01234Uses a finger or marker to keep place01234Reads very slowly01234Poor reading comprehension or it worsens over time01234Holds books close or leans in too close to papers and screens01234Squints, closes or covers one eye while reading01234Poor posture or tilts head when reading or writing01234Unusually tired, or falls asleep after completing a visual task01234Difficulty copying from board01234Crooked or poorly spaced writing01234Print moves or goes in and out of focus when reading01234Words overlap, run together or appear to jump when reading01234Misaligns letters or numbers especially in columns01234Clumsy, accident prone or poor coordination01234Poor, inconsistent performance in sports01234Loses concentration when doing close work, short attention span01234Avoids near tasks such as reading01234Confuses right and left directions01234Car sickness or motion sickness01234Burning, watery or red eyes01234Excessive blinking or eye rubbing01234Daydreaming01234Sensitivity to light01234Difficulty completing assignments in reasonable time01234Headaches or eyes hurt while watching "3D" movies01234Reading below grade level, finds reading a chore01234SCHOOL HISTORYAverage School WorkAbove AverageAverageBelow AverageBest SubjectHardest SubjectAge Started KindergartenGrades RepeatedReasonAttitude Toward SchoolDescribe any special tutoring, therapy, and/or remedial assistance (IEP,504) including when, from whom, how long and resultsDescribe any Problem Associated with SchoolDEVELOPMENTAL HISTORYComplications During PregnancyDuring/After BirthBirth WeightUntitled 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)AccidentsEye or Head InjuriesFamily DoctorDate of Last PhysicalDescribe Any SurgeryOther Conditions Which May Affect DevelopmentHas your child ever had a Neurological evaluation?Date/LocationPsychological evaluation?Date/LocationHearing and/or Speech evaluation?Date/LocationOccupational and/or Physical Therapy evaluation?Date/LocationFAMILY 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 PERSONSignature
