Pediatric History Form (Ages 5 and Under) "*" indicates required fields Preferred First Name:* Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Parent(s) / Guardian(s):* Grade and School: Activities or Sports: Time spent on Electronic Devices: Child's Doctor/Clinic:* Last Medical Exam:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Main concern for today's visit:*Eye History: Have you ever noticed any of the following with your child’s eyes (Please check all that apply)? White appearance in pupil:* No Yes Eye:*RightLeftBothEye(s) turn (in or out):* No Yes Eye:*RightLeftBothRubbing of eyes:* No Yes Eye:*RightLeftBothWatery eyes:* No Yes Eye:*RightLeftBothRed eyes:* No Yes Eye:*RightLeftBothOther:Developmental and Health History Please list any complications/issues during pregnancy:Please list any medical conditions:Please list any abnormal childhood illnesses:Please list any medications, vitamins, or supplements:Please list any accidents, eye or head injuries:Please list any food or drug allergies:Please list any developmental delays or concerns: Family History: Do any family members: Wear Glasses / Contacts?* No Yes Whom? Have a lazy eye (amblyopia)?* No Yes Whom? Have an eye turn (strabismus)?* No Yes Whom? Have an eye disease?* No Yes Whom? Please list any family members with any other eye problems: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.Parent/Guardian signature:* Reset signature Signature locked. Reset to sign again DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
