Today's Date (MM/DD/YYYY)

Child's Name

Please list any medications that your child is allergic to:

Male Female Date of Birth: (MM/DD/YYYY)

Reason for your visit:

Has your child ever been given a prescription for glasses in the past? Yes No

If yes, why were glasses prescribed?

Has your child ever worn a patch to treat amblyopia or lazy eye? Yes No

If yes, for how long did your child wear the patch, and is your child still wearing it on a regular basis?

Has your child ever had crossing or turning of the eye(s) Yes No

And if yes, when did the problem begin?

Has your child ever had eye muscle surgery? Yes No

If yes, for what reason was the surgery performed and at what age?

Has your child ever had surgery for a blocked tear duct? Yes No

Has your child ever been diagnosed with cataracts? Yes No

If yes, was cataract surgery performed? Yes No

If yes, which eyes had surgery? Left Right Both

Has your child ever received eye drops in the past? Yes No

If yes, which drops were prescribed and for what reason?

Is your child presently receiving eye drops of any kind including over the counter drops? Yes No

If yes, please list:

Does your child receive any medications by mouth or topically to the skin? Yes No

If yes, please list:

Does your child have any of the following disorders: (check all that apply)

Was your child born prematurely? Yes No

If yes, at how many weeks was your child born?