Patient Intake (CHILD) Name First Last DOB MM slash DD slash YYYY Gender at Birth: Male Female Pronoun preference:Gender Identity: Non-Binary Male Female Name of Parent(s)-If separated/divorced please provide contact information for each parentMother* Phone*Email* Father PhoneEmail Child Glaucoma Cataracts Crossed/Lazy Eye Macular Degeneration Retinal Detachment Blindness Foreign Body Removal Ocular Surgery/Lasik Colour Blindness Hypertension Heart Problem Stroke Thyroid Condition Asthma Allergies HIV/ Hepatitis Cancer Neuromuscular/MS Arthritis/ Automimmune Family Glaucoma Cataracts Crossed/Lazy Eye Macular Degeneration Retinal Detachment Blindness Foreign Body Removal Ocular Surgery/Lasik Colour Blindness Hypertension Heart Problem Stroke Thyroid Condition Asthma Allergies HIV/ Hepatitis Cancer Neuromuscular/MS Arthritis/ Automimmune Type Type Do you notice your child Squinting Rubbing eye Avoiding Detailed Close Activities Eye wandering/crossing Not performing at grade level or as expected at school Does your child complain of Blurry Vision Eyes hurt Itchy eyes Watering eyes Sandy or Dry Eye Trouble seeing board/copying from board Double vision Trouble with reading/ words jumping Difficulty concentrating / short attention span Letter reversals/trouble seeing difference between letters Losing place while reading Trouble remembering sight words Family Dr. Allergies Head Injury/Concussion? At time of birth was patient full term? Pre-term? (indicate weeks) Any developmental milestones delays? Medications
