Child Patient Form

2260 Oakmont Way, Suite 1 | Eugene, OR 97401

P 541.342.4243 | F 541.284.2958 | foleyvisioncenter.com

General Information

Today's Date:

* Full Legal Name

Preferred Name

* Birth Date

* SSN (last 4 digits):

* Address

* City

* State

* Zip

Phone

* Preferred
Home Work Cell

Mother
Home Work Cell

Father
Home Work Cell

Guardian
Home Work Cell

* OK to text Preferred Phone Number?
Yes No

* Preferred

Mother

Father

Guardian

Preferred Pronoun (he/she/they):

Referred By:

Grade:

School:

How did you hear about us?

* Race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiin or Other Pacific Islander

White

Unknown/Decline to Provide

* Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Decline to Provide

* Preferred Language:

English

Spanish

Other:

Per the Health Care Act we are required to record your child's height and weight at each visit.

* Height

ft.in.

* Weight

lbs.

Insurance Information

* Do you have vision insurance?

Yes

Patients with Insurance: At the time of treatment, patients are expected to pay their estimated charges. An estimate of cost will be provided to you at the time of your appointment. Insurance portion is only an estimate and any balance remaining after insurance payment is patient's responsibility.

Patients without Insurance: Patients without insurance are required to pay the charges in full at the time service is provided. A total cost will be provided to you at the end of your appointment.

Please fill out any vision insurance below. Policy numbers may change even if your coverage has remained the same, so please fill out every year. If information is missing or incorrect, your visit may not be billed correctly to your insurance.
Please answer “N/A” if you do not have coverage.

Insurance Company Name (Vision)

ID #

Group #

Name of Primary Member Insured (as it appears on insurance card)

Birth Date of Primary Member Insured

SSN (last 4 digits) of Primary Member Insured

Relationship to Primary Member Insured

Self Spouse/Partner Parent/Guardian Other

Please fill out any medical insurance below. Policy numbers may change even if your coverage has remained the same, so please fill out every year. If information is missing or incorrect, your visit may not be billed correctly to your insurance.
Please answer “N/A” if you do not have coverage.

* Insurance Company Name (Medical)

* ID #

* Group #

* Name of Primary Member

* Birth Date of Primary Member Insured

* SSN (last 4 digits) of Primary Member Insured

Relationship to Primary Member Insured:

Self Spouse/Partner Parent/Guardian Other

There may be instances when we need to contact other healthcare practitioners you see. Please list below:

Primary Care Practitioner:

Name

Additional Providers:

Name

Type of Care

Name

Type of Care

Name

Type of Care

CHIEF COMPLAINTS TODAY (or over the last week)

Allergies

Blurred Vision Distance

Blurred Vision Near

Blurred Vision on Computer

Burning/Stinging

Difficulty driving during the day

Difficulty driving at night

Discharge

Double Vision

Dryness

Eye Strain/Fatigue

Floaters/Spots

Flashes

Glare/Sensitivity to Light

Foreign Body Sensation

Headache

Itching

Loss of Vision

Loss of Side Vision

Pain/Discomfort

Redness

Scratchy/Gritty

Watering/Tearing

Other:

*Is there any evidence from school or psychological tests that some visual malfunction may be present?
Yes No If so, what?

Confuses letters or words

Yes No

Reverses letters or words

Yes No

Skips, rereads or omits words

Yes No

Vocalizes when reading silently

Yes No

Reads slowly

Yes No

Uses finger as a marker

Yes No

Poor reading comprehension

Yes No

Writes or prints poorly

Yes No

Tires easily

Yes No

Avoids near tasks

Yes No

Short attention span

Yes No

Poor motor coordination

Yes No

Difficulty catching/hitting a ball

Yes No

GLASSES

* Does your child wear glasses?

Yes

If yes, what for?

Near

Distance

Both

If yes, what type?

Single Vision

Progressive

Bifocals

Trifocals

Any Problems?

Do you plan on purchasing new glasses today?

Yes

If RX changed

CONTACTS

* Does your child wear contacts?

Yes

If yes, how frequently does your child wear them?

Full Time

Occasional

Rarely

If yes, what type?

Daily Disposable Soft Lenses

Monthly/Bi-Weekly Replacement Soft Lenses

Extended Wear Soft Lenses

Rigid Gas Permeable (RGP)

Multi-Focal

CRT

Scleral

If no, are you interested in contact lenses?

Yes

Which cleaning solution does your child use?

Average Wear Time:

hours

* Just a reminder a $55-75 contact lens evaluation fee is charged for annual contact lens exams.

ALLERGY SURVEY

* Does your child EVER suffer from red eyes, itchy eyes, watery eyes, or swollen eye lids?

Yes No If yes: Seasonal All Year

Does your child EVER use over-the-counter or prescribed eye drops (i.e. VISINE A, VISINE AC, OPCON A, etc.) to treat red eyes, itchy eyes, watery eyes, or swollen eye lids?

Yes No If yes, please list:

Does your child take any prescribed or over the counter medications like CLARITIN, ALLEGRA, or ZYRTEC for their allergies?

Yes No If yes, please list:

SURGICAL HISTORY

* Ocular (retinal detachment, strabismus)

Yes No If yes, please explain:

* Surgical (wisdom teeth, tonsils, appendix)

Yes No If yes, please explain:

MEDICAL HISTORY

* Does your child have any allergies to medications?

Yes No If yes, please explain:

Other Allergies (foods, pollens, etc.):

* Has your child taken or is taking Accutane medication?

Yes No

COVID VACCINES * Has your child had a COVID-19 vaccine?

Yes

What type (Pfizer, Moderna, J&J)?

2nd dose date?

Booster date?

In the past two weeks, has your child had exposure to an individual diagnosed with COVID-19?

In the past two weeks, has your child had any COVID-19 symptoms (fever, chills, cough, shortness of breath, etc)?

Has your child been diagnosed as having (Please check all that apply):

Learning Disabilities

Developmental Delays

ADD or ADHD

Cerebral Palsy

Seizure Disorders

Autism

Asthma

Hormone Replacement Therapy

Does your child currently receive:

Occupational therapy services

By Whom:

Results?

Physical therapy services

By Whom:

Results?

Speech therapy services

By Whom:

Results?

List any medications your child takes, Rx or OTC/Supplements and Condition

If you don’t know what condition per medication, please put “Unknown”

Rx or OTC/Supplement

Condition

Rx or OTC/Supplement

Condition

Rx or OTC/Supplement

Condition

Rx or OTC/Supplement

Condition

Please list additional medications here:

DEVELOPMENTAL HISTORY

* Walked at Months

Please check all that apply:

Normal Term Birth (Full Term)

Premature Term Birth

Low Birth Weight

Over Term Birth

Complications at Birth

Crawled Normally

Did Not Crawl for Long

Crawled Longer Than Usual

High Fevers

Normal Temperament

Becomes Irritable

Learning Difficulties

Speech Difficulties

Reduced Fine-Motor Skills

Reduced Gross-Motor Skills

Childhood Concussion

Bad Fall(s)

Head Injuries

OCULAR:

Amblyopia (Lazy Eye)

SelfFamily

Blindness

SelfFamily

Cataract(s)

SelfFamily

Color Deficiency

SelfFamily

Glaucoma

SelfFamily

Keratoconus

SelfFamily

Macular Degeneration

SelfFamily

Ptosis (Drooping Lid)

SelfFamily

Retinal Detachment

SelfFamily

Retinal Tear

SelfFamily

Strabismus (Eye Turn)

SelfFamily

Other:

SelfFamily

MEDICAL:

Androgen Deficiency

SelfFamily

Arthritis

SelfFamily

Acne Rosacea

SelfFamily

Cancer

SelfFamily

Type?

Cholesterol

SelfFamily

Crohns

SelfFamily

Diabetes Type 1

SelfFamily

If self, last reported A1c:

Last reported blood sugar?

Diabetes Type 2

SelfFamily

If self, last reported A1c:

Last reported blood sugar?

Ehlo's Danlos Syndrome

SelfFamily

Facial Herpes Zoster (Shingles)

SelfFamily

Heart Disease

SelfFamily

Hepatitis C

SelfFamily

High Blood Pressure

SelfFamily

Kidney Disease

SelfFamily

Lupus

SelfFamily

Migraines

SelfFamily

Sarcoidosis

SelfFamily

Sjogren's Syndrome

SelfFamily

Sleep Disorders

SelfFamily

Stroke

SelfFamily

Thyroid Disease

SelfFamily

Other:

SelfFamily

SCHOOL

* Does your child like school? Yes No

* Does your child like to read? Yes No

* Has your child had any special tutoring and/or remedial assistance? : Yes No

When?

From Whom?

Where?

How Long?

Results:

Please estimate your child's daily screen time. Note: All fields required, please enter 0 if appropriate. Thank you!

* Time on a computer

* Cell phone/Tablet/Kindle

* How many hours does your child spend outdoors per day?

VISUAL HISTORY

* Were glasses prescribed? Yes No

Are they worn? Yes No

When?

Results:

Members of the family who have had visual attention and why:

Name

Age

Visual Situation

Name

Age

Visual Situation

Name

Age

Visual Situation

FAMILY AND HOME

Please indicate which adult(s) your child lives with:

Mother

Father

Grandparent

Foster Parents

Step Father

Step Mother

Our goal is to provide the best, most complete, up-to-date care available. Our philosophy is preventive and developmental in approach. To provide this service in the most efficient manner, please be aware of the following office policies:

Fees for services are due at the time those services are rendered.
Payment in full at time of ordering.
We reserve the right to charge for missed appointments not canceled in advance.
Vision Therapy patients must notify us of absences in advance.
There is a charge for written reports.
Responsibility for payment is the patient’s. Insurance agreements are between the company and the patient. We will assist with proper forms but require reimbursement from patients.

By signing this form electronically, and clicking on “Submit Form,” you are agreeing to the terms and conditions stated herein. The signee understands this is a legal representation of their written signature.

* Print Your Legal Name

Signature
If using a touch screen device, use your finger to sign. If using a computer, hold down the left button and use the mouse as a pen.

* Date: