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Simpson and Mann Child Registration
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2018-10-19T19:42:10+00:00
Simpson and Mann Child Registration Form
Today's Date
Date Format: MM slash DD slash YYYY
Child's Name
First
Last
Age
Birthdate
Date Format: MM slash DD slash YYYY
Date of child's last eye examination
Date Format: MM slash DD slash YYYY
Has child ever had vision therapy?
Yes
No
Has child ever worn glasses?
Yes
No
Does he/she wear glasses now?
Yes
No
If yes, are glasses for
Distance only
Near only
Full time wear
Does child wear contact lenses?
Yes
No
Any problems with contact lenses?
What is your main reason for this visit?
Have you noticed and unusual signs or symptoms that concern you?
Has your child's ability to do any activity been restricted because of vision?
Select all that apply to your child
Allergies
Respiratory disease
Cancer
Diabetes
Drug sensitive
Heart problems
High blood pressure
Thyroid
Migraine or headaches
Blindness
Head trauma
Lazy eye
Turned eye
Color "blind"
Light sensitive
Eyestrain
Dry eyes
Floaters/spots
Retinal detachment
Cataracts
Glaucoma
Eye surgery or injury
Select all that run in your family
Allergies
Respiratory disease
Cancer
Diabetes
Drug sensitive
Heart problems
High blood pressure
Thyroid
Migraine or headaches
Blindness
Head trauma
Lazy eye
Turned eye
Color "blind"
Light sensitive
Eyestrain
Dry eyes
Floaters/spots
Retinal detachment
Cataracts
Glaucoma
Eye surgery or injury
Is your child currently under a physician's care?
Yes
No
Why is your child currently under a physician's care?
Is your child regularly taking pills or medication?
Yes
No
What medication is your child currently taking? Specify
Date of child's last physical
Date Format: MM slash DD slash YYYY
How is child's general health?
Developmental Milestones
Full term pregnancy
Yes
No
Normal birth?
Yes
No
Any complications before, during, or immediately following delivery?
Yes
No
Describe any complications related to delivery
Did your child creep (stomach on floor)?
Yes
No
At what age did your child creep?
Did your child crawl (stomach off floor)?
Yes
No
At what age did your child crawl?
Did your child move around on all fours?
Yes
No
At what age did your child move around on all fours?
At what age did your child walk?
Was your child active?
Yes
No
At what age were your child's first words?
Was early speech clear to others?
Yes
No
Is speech clear now?
Yes
No
Have any of your children had difficulty in school?
Yes
No
Please describe difficulty in school
How do you feel your child is doing in school?
Well
Below potential
Poorly
Please select the signs and symptoms that best describe how your child is doing in school
Does your child squint when looking up from reading?
Have trouble seeing the chalkboard?
Frequently blink or rub eyes?
Have headaches after doing school work?
Frequently awkward, bump into things, knock things over?
Hold books extremely close?
Read a great deal of the time?
Report that things look blurry?
Have trouble copying work from the chalkboard to paper?
Spend a long time doing homework that should only take a few minutes?
Reduced attention span, can concentrate for only a moderate time?
Covers one eye by leaning on hand?
Lays head on desk when doing pencil work?
Frequently loses place when reading?
Skips or re-reads words and lines?
Reverses words or letters (was for saw, b for d) beyond second grade?
Does better at math than English, history or social studies?
Must re-read material several times to grasp its meaning?
Gets tired quickly when doing reading or homework?
Short attention span? Can concentrate on reading work for only a few minutes.
Daydreams a lot? Stares off into the distance frequently?
Learns best through auditory tactics (listens to learn)?
Misbehavior has become a problem (to cover up poor school performance)?
Acts up when asked to do school work
Class clown, "goofs off"
Moody or depressed about school and life
Aggressive, hits or dominates other children
Avoids work that includes reading or near seeing?
Is more than 1 year behind group in reading-related skills?
Has poor posture? Slouches, slumps in chair?
In what recreational activities does your child participate?
Read
Baseball
Basketball
Soccer
Swims
Build models
Sew
Dance
Perform
Plays an instrument
Other
Other recreational or sports activities?
Does your child wear protective eyewear for his/her sport?
Yes
No
Does your child watch much television?
Yes
No
Number of hours daily watching television
Does your child use a computer at home?
Yes
No
Does your child use a computer at school?
Yes
No
Number of hours daily using computer
Does your child often play video games?
Yes
No
Number of hours daily playing video games
Does your child play hand-held video games?
Yes
No
Screen type
Bright
Dim
We are happy to assist you in the filing of your insurance claim. If your insurance will not pay the anticipated amount, or your insurance pays you directly, we ask that you pay the balance. Office policy calls for payment at the time of service. If eyewear or contact lenses are to be ordered, a minimum 50% deposit is requested and the balance is due upon delivery. We accept cash, personal checks, Visa, and Mastercard. A monthly rebilling fee of $5 is added to all accounts with unpaid balances after 30 days. I have read and agree to all of the provisions of the office of financial policy. I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry
Signature
Date
Date Format: MM slash DD slash YYYY
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