Infant Toddler Patient Form

General Information

Today's Date:

Child’s First & Last Name

Nick Name

Birth Date

Note: Mother's Name, Father's Name, and Guardian's Name are required fields. Please enter n/a as needed.

Mother’s Name:

Father’s Name:

Guardian’s Name:

Is your child especially afraid of Doctors?
Yes No

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

Height:

Weight:

MEDICAL HISTORY

Has your child been prone to infection?

Yes No

Doctor’s Name:

Chronic problems like hay fever, asthma, or allergies?

Yes No

Has a neurological or psychological evaluation been performed?

No Yes Date :

By Whom:

Results?

Has a Psychological evaluation been performed?

No Yes Date :

By Whom:

Results?

List illnesses, bad falls, high fever, asthma or allergies:

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

Age

Condition

Severe Mild

DEVELOPMENTAL HISTORY

Please check all that apply:

READING/COMPUTER SYSTEM CHECKLIST

DEVELOPMENTAL HISTORY

Please check all that apply:

What percent of the waking hours is your child in a:

Playpen?

Walker?

Seat?

What things can your child do very well?

What things, if any, are difficult for your child?

Where appropriate, list your child’s age when he/she could do the following:

Responsive smile

Sit up (without support)

Creep (stomach off floor)

Responded to words or names

Stacked blocks

Walked up steps with help

Gave first name

Became toilet trained

Rolled over

Walked (without support)

Talk (string two words)

Good “all-fours crawling”?

Scribbled spontaneously

Kicked a ball

Used two-word sentences

Put on some clothing alone

NUTRITIONAL INFORMATION:

What is your child’s activity level? Low Moderate High

Current diet: Nursing: Never Now Nursed Until Solid

Solid food started:

What type?

Have you noted extreme fatigue?

No Yes If so, when?

Does fatigue result in a sag, excitability or irritability? ?

Yes No

Is your child’s visual difficulty more noticeable with fatigue?

Yes No

Is there any tensional behavior such as nail biting, eye blinking or rubbing (other than normal sleepiness), tantrum, tongue chewing or extension

No Yes If so, when?

Do any of these tensional behaviors seem related to preschool, movies or TV?

Yes No

PRESENT SITUATIONS:

Please check YES or NO to the following observations and/or complaints as they relate to your child:
Symptom:

Eyes crossed-turning in or out at any time or eyes that do not appear straight, especially when child is tired.

Yes No

Has reddened eyes or eyelids

Yes No

Has encrusted lids

Yes No

Has frequent sties

Yes No

Eyes in constant motion

Yes No

Eyelids droop

Yes No

Complains of burning or itching eyes

Yes No

Complains of pain in eyes

Yes No

Stares at bright lights frequently

Yes No

Is abnormally bothered by bright lights

Yes No

Has watery eyes

Yes No

Thrusts the head forwards or backwards while looking at distant objects

Yes No

Turns the head to use one eye only

Yes No

Tilts the head to one side

Yes No

Squints while looking at objects

Yes No

Blinks excessively

Yes No

Has a tendency to rub eyes

Yes No

Covers or closes one eye

Yes No

Stumbles over objects

Yes No

Lacks interest in looking at objects or seeing

Yes No

Unable to see distant objects

Yes No

Transfers objects from hand to hand, crossing the middle of the body

Yes No

Is unable to stack blocks or other objects

Yes No

Electronic Device Usage at Home and School (phone, tablet, desktop, laptop):

How much?

How often?

Viewing distance

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

Name

Age

Visual Situation

Name

Age

Visual Situation

Name

Age

Visual Situation

Name

Age

Visual Situation

Name

Age

Visual Situation

GENERAL BEHAVIOR

Do you have any concerns about your child’s behavior?

Yes No If so, what are they?

Has there been any recent or ongoing emotional difficulties?

Yes No If so, what are they?

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

FAMILY AND HOME

Family Member

Birth Date / Age

Visual Situation

Family Member

Birth Date / Age

Visual Situation

Family Member

Birth Date / Age

Visual Situation

Family Member

Birth Date / Age

Visual Situation

Family Member

Birth Date / Age

Visual Situation

Is there any history of mental retardation, psychological disturbance, etc., in the family?

Has anyone in the family had:

Please use this space to write a brief description of your child as a person.

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.

Signature

Date:

Infant/Toddler Developmental History Form