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Simpson and Mann Infant Registration
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2018-10-19T19:43:54+00:00
Simpson and Mann Infant and Preschool Registration
Date of Exam
MM slash DD slash YYYY
Name
First
Middle
Last
Nickname
Gender
Male
Female
Date of birth
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Social Security #
Mother's Name
First
Last
Mother's occupation
Mother's work phone
Mother's Social Security #
Father's Name
First
Last
Father's Occupation
Father's work phone
Father's Social Security #
Names and ages of family members living at home
Referred by
Physician's Name
First
Last
Physicians's Phone
Vision Insurance
VSP
MES
Other
If other, what vision insurance do you have?
Insured by
Mother
Father
Major medical insurance
AETNA
MEDI-CAL
Healthy Families
Other
If other, what medical insurance do you have?
Insured by
Mother
Father
Main reason for exam
No problem- general checkup
Eyes turn in
Eyes turn out
Red/crusty eyes
Blurred vision
Squint eyes
Rubs eyes excessively
eyes tear excessively
2nd Opinion
Visual problems in other family members
Eye or head injury
Doctor referred
Other
Main reason for exam
My child is
Natural
Adopted
Foster
Other
Length of pregnancy
Less than 7 months
7-8 months
8-9 months
Over 9 months
During pregnancy of this child, which, if any of the following occurred:
Toxemia
Smoking
Little Obstetrical Care
Injury by Fall
Prescribed Medication
Severe Illness
Trauma
Use of drugs
Use of alcohol
Additional explanation of pregnancy:
Type of Delivery:
Natural
Caesarian
Forceps/Vacuum
Anesthesia
Other
Were there any problems during delivery?
Yes
No
What problems during the delivery?
Child's Birth Weight
Is your child currently taking any medication?
Yes
No
List medications and purpose
Does your child have a history of:
High fever
Ear infections
Epilepsy or seizures
Medication allergies
Allergies
Has child had any of the following?
Glasses
Patching
Vision therapy
Eye surgery
Additional Eye History Info?
Has any blood relative had:
Macular Degeneration
Cataracts
Diabetes
Glaucoma
Lazy Eye
Heart Disease
High Blood Pressure
Retinal Problems
Eye Turn
Learning Disability
Developmental Stages:
Eye control 180 degrees - average age 3 months
Early
Normal
Late
Unsure
Head control - average age 3 months
Early
Normal
Late
Unsure
Hand grasp - average age 4 months
Early
Normal
Late
Unsure
Sits without support- average age 6.5 months
Early
Normal
Late
Unsure
Walks unaided- average age 12 months
Early
Normal
Late
Unsure
Scribbles Spontaneously- average age 15 months
Early
Normal
Late
Unsure
Combines 2 Different Words- average age 21 months
Early
Normal
Late
Unsure
Copies Circle- average age 3 years
Early
Normal
Late
Unsure
Rides Tricycle- average age 3 years
Early
Normal
Late
Unsure
Knows Colors- average age 4 years
Early
Normal
Late
Unsure
List all previous evaluations done on your child
Doctor or Institution
Date
Type of Evaluation
Results/Treatment/Intervention
Individuals or agencies that you wish to receive the results of our exam
Name
Address
Further comments?
PAYMENT TERMS: 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 the provisions of the office financial policy I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry
Relation to child
Signature
Date
MM slash DD slash YYYY
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