Village of Cross Keys Quadrangle, 2 Hamill Road, Suite 345, Baltimore, MD 21210, (410) 433-8488, Fax (410) 435-2331
RiverHill Professional Center, 6100 Day Long Lane, Suite 207, Clarksville, MD 21029, (443) 535-8755
South Carroll Medical Center, 1380 Progress Way, Suite 108, Eldersburg, MD 21784, (410) 795-9590
Phyllis L. Green Professional Building, 826 Washington Road, Suite 200, Westminster, MD 21157, (410) 876-9030 |
| Patient’s Name |
LAST FIRST MIDDLE
|
NICKNAME IF ANY
|
SEX
M F |
AGE
|
ADDRESS
|
CITY/STATE, ZIP CODE
|
Email
|
HOME PHONE
|
CELL PHONE
|
DATE OF BIRTH
|
DOES PATIENT NOW WEAR GLASSES OR CONTACT LENSES?
No Yes
IF YES, PLEASE REMEMBER TO BRING THEM WITH YOU. |
| Reason For This Visit To Our Office |
|
| Insurance Information |
PATIENT’S SOCIAL SECURITY NUMBER
|
INSURANCE
|
INSURANCE I.D. NO.
|
For Pediatric Patients ONLY
Are You The Natural Parents Of This Child? |
MOTHER’S NAME (LAST NAME, FIRST NAME, MAIDEN NAME)
|
HOME PHONE
|
WORK PHONE
|
ADDRESS (IF DIFFERENT FROM PATIENT)
|
CITY/STATE/ZIP CODE
|
FATHER’S NAME (LAST NAME, FIRST NAME)
|
HOME PHONE
|
WORK PHONE
|
ADDRESS (IF DIFFERENT FROM PATIENT)
|
CITY/STATE/ZIP CODE
|
| As A Parent, Are You An Active Member of Any Parent Or Child Related Group? |
NAME OF GROUP OR ASSOCIATION
|
WHO BELONGS
|
MOTHER
|
FATHER
|
| Patient’s Pediatrician Or Regular Physician |
DOCTOR’S NAME (FIRST AND LAST NAME)
|
PHONE
|
ADDRESS
|
CITY/STATE/ZIP CODE
|
DID THE ABOVE DOCTOR REFER YOU TO US?
YES NO → |
IF NO, NAME AND ADDRESS OF DOCTOR OR PERSON WHO REFERRED YOU:
|
List Immediate Family Members Of This Patient
*Check Who Has Been Seen At Our Office |
NAME
|
Age
|
*Check
|
NAME
|
| Does Anyone In Patient’s Family Have A History Of Any Of These Eye Conditions? |
STRABISMUS (CROSSED EYES) No Yes →
RELATIONSHIP TO PARENT |
GLAUCOMA No Yes →
RELATIONSHIP TO PARENT |
AMBLYOPHIA No Yes →
RELATIONSHIP TO PARENT |
COLOR BLINDNESS No Yes →
RELATIONSHIP TO PARENT |
CATARACTS No Yes →
RELATIONSHIP TO PARENT |
OTHER EYE DISEASES No
Yes →
RELATIONSHIP TO PARENT
IF YES, PLEASE SPECIFY:
|
| Who In The Family Wears Glasses Or Contact Lenses? |
MOTHER
Reason:
MYOPIC (NEAR-SIGHTED)
HYPERIPIC (FAR-SIGHTED)
ASTIGMATISM |
FATHER
Reason:
MYOPIC (NEAR-SIGHTED)
HYPERIPIC (FAR-SIGHTED)
ASTIGMATISM |
BROTHER
SISTER
Reason:
MYOPIC (NEAR-SIGHTED)
HYPEROPIC (FAR-SIGHTED)
ASTIGMATISM |
BROTHER
SISTER
Reason:
MYOPIC (NEAR-SIGHTED)
HYPERIPIC (FAR-SIGHTED)
ASTIGMATISM |
| PATIENT’S MEDICAL HISTORY |
For Pediatric Patients ONLY
Patient’s Birth-Related History |
Weight at birth: lbs. oz. |
Was patient premature? No Yes →
If yes, by how many weeks? |
| Did patient receive oxygen therapy at birth? No Yes → If yes, how long? |
Did patient have any infections or other medical problems at birth? No Yes → If yes, please explain:
|
Did patient have juandice? No Yes → If yes, was patient placed under light therapy? No Yes
If yes, for how long? |
Did patient have any respiratory problems at birth? No Yes → If yes, please explain:
|
Did patient have any eye problems at birth? No Yes → If yes, please explain:
|
All Patients
Patient’s Medical History |
Is patient taking any medication at this time? No Yes → If yes, name of medication:
Reason for taking: |
| Does patient have any seasonal allergies (e.g. hay fever) No Yes → If yes, what kind? |
Has patient had any unfavorable reactions to medications? No Yes → If yes, name of medication:
|
Has patient ever had surgery? No Yes →
If yes, what kind? |
Was patient ever hospitalized for medical problems? No Yes → If yes, what kind:
|
Are there any hereditary medical problems in patient’s family? No Yes → If yes, what kind:
|
| Patient’s Complaints |
Does patient complain of any visual disturbances when reading? (Blurry vision, double vision, tearing, aching eyes)?
No Yes → If yes, please explain: |
Does patient ever complain of frequent headaches? No Yes → If yes, please explain?
|
| Developmental History & Learning Problems |
Hearing deficiencies
Speech deficiencies
Emotional difficulties
Behaviorial difficulties |
Delayed growth
Developmental delays
Attention deficit |
Dylexia (Reading Disability)
Hyperactivity
Other Learning Disabilities
Other |
| Additional Patient Information |
NEUROLOGICAL PROBLEMS
Cerebral Palsy
Seizure Disorders
Mental Retardation
Autism
Brain Tumor
Severe Head Injury
Other: |
INFECTIOUS DISEASES
Measles (Rubella)
Chickenpox
Polio
Herpes
Parasites (Toxoplasmosis)
Other: |
BLOOD DISORDERS
Bruises easily
Sickle Cell trait/disease
Anemia
HIV
Other: |
OTHER MEDICAL
Migraines
Sinusitis
Diabetes
Asthma
Arthritis
Heart Problems
Other: |
Additional Comments:
|
| Thank you… for providing the information requested. It will help us to serve you better and save time when you arrive at our office. |
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