Infant See

InfantSEETM Confidential Infant History Assessment Date: ______/______/______ Name:__________________________________________ Home Phone:______________________________

Male___ Female___

DOB:____/____/____

Hispanic | Caucasian | African American | Native American | Asian | Pacific Islander

Home Address:___________________________________________________________________________________ Street City State Zip Code Parent(s) or Guardian(s):___________________________Adult(s) Occupation:________________ How did you learn about our program? c Current patients Website

c

c

c

Referred by friends/family

Story in Newspaper/ on TV

c

c

Print Ads

c

Radio Ads

Referred by Dr.__________________________

Eye History Have you ever noticed any of the following happening with your baby’s eyes? Eye turn: c in

c

out

c

Eyes watering

c

Eyes red

c

(please check any that apply)

Swelling around the eyes

c

White appearance in pupil

Explain any eye concerns noted by observing child:______________________________________________________ _______________________________________________________________________________________________ Developmental and Health History PREGNANCY Length of pregnancy: ______weeks List any complications during pregnancy:________________________________ Other pregnancy issues:____________________________________________________________________________ DELIVERY BirthWeight_________________

Parents ages at time of birth: Mother_________ Father_________

List any complications during delivery:_________________________________________________________________ Was oxygen used? c No

c

Yes

APGAR score at birth:_________ (if known)

MEDICAL Child’s Doctor:_________________________Last Exam Date:_________ Are immunizations up to date? c Yes Does your baby have any food or drug allergies? List ALL medications taken regularly:

c

c

No

c

c

No

Yes:____________________________________________

None List:______________________________________________________

List any developmental delays:______________________________________________________________________ Check all of the following that your baby can do at this time: Has your baby ever had a high temperature (fever)?

c

No

c

c

Roll Over

c

Sit

c

Crawl

c

Stand

c

Walk

Yes, how high?___________

Please list any childhood ilnesses your baby has had: ___________________________Illness

_____Age at the time.

Was the illness?

c

Mild

c

Moderate

c

Severe

___________________________Illness

_____Age at the time.

Was the illness?

c

Mild

c

Moderate

c

Severe

List any accicents, eye, or head injuries, and the age they occurred:_________________________________________ Please list any other conditions we should know about:___________________________________________________ Family History Do any family members have: Lazy eye (amblyopia) cYes cNo Eye turn (strabismus) cYes cNo Eye tumor

Yes cNo

c

Please list any family members with a history of other eye or medical problems. List the relation and type of problem:

I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of my child’s eyes and vision. I understand that the InfantSeeTM vision assessment is without charge. If further services or treatments are recommended, I may choose any care professional to provide those services. ___________________________________________ Parent/Guardian Signature

Date: _______/_______/_______

Thank you for carefully completing this confidential questionaire. This information will allow for a more efficient use of examination time and will contribute to the understanding of infant eye and vision development.