CHILD HX FORMS PACKET with 10 point symptom survey

Name

First Middle Last

DOB:

Preferred Name:

Age:

Grade:

School:

Mother/Guardian Name:

Occupation:

Father/Guardian Name:

Occupation:

Parents Status:

Married

Divorced/Separated

Child living with:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:

Cell Phone:

Other Phone:

Which phone you Preferred

Home Phone:

Cell Phone:

Other Phone:

Non-Guardian Emergency Contact:

Phone Number:

Primary insurance:

Secondary Insurance:

Family Eye Doctor:

Last Eye Exam:

Referred By: (Check all that apply)

Medical Information

Pediatrician’s Name:

Date of Last Exam:

Does the Pediatrician have any areas of concern regarding the child’s health?

Have you received any of the following examinations? Check any that appy and write down in the name of the provider.

Neuropsychological:

Occupational Therapist:

Speech/Hearing Specialist:

Other Specialist:

Name of the provider

Results/Recommendations:

History of Head Injury/Stroke/Other Neurological Insult:

Born Premature or Complications at Delivery:

Developmental History

Delays in gross motor development (i.e. difficulties learning to ride a bike, catch a ball, play sports, etc.)?

Yes

Explain

Delays in fine motor development (i.e. difficulties learning to use scissors, tie shoes, draw/write, etc.)?

Yes

Explain

Delays in learning to crawl or walk? (please note if child skipped crawling)

Yes

Explain

Other Developmental Delays

Yes

Explain

Take Our Convergence Insufficiency Symptom Survey

Did your child repeat a grade or have a delayed start?

Yes

Explain:

Has your child received special tutoring or remedial assistance?

Yes

Explain:

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

Yes

Explain:

Has your child ever had a head injury/stroke/Other Neurological Insult?

Yes

Explain:

Is your child performing up to their potential?

Is there any other information you feel would be helpful/important in our treatment of your child?

Strabismus/Amblyopia (Wandering/Crossed or Lazy Eyes) – Circle all that apply

Direction of wandering eye?

Inward

Outward

Down

Which Eye?

Right

Left

Both

At what age did you or others first notice the eye wander?

Have reduced vision in one eye even after corrected with glasses?

Right Eye

Left Eye

Both Eyes

Neither

Patching

Yes

How long?

Kind of patching?

Black patch

Eye Drops

Other

Describe:

At what age was your child first diagnosed with Amblyopia (reduced vision in one eye with glasses)?

At what age did your child start wearing glasses?

Patient’s Name:

First Last

DOB:

Date:

Review of Systems

Please mark each box. Indicate Yes or No for any current diagnoses or symptoms for the following.

General Constitutional (Unexplained fever, weight loss or gain, etc.)

Yes

Please describe

Eyes: (Disease related such as Glaucoma, Detached Retina)

Yes

Please describe

Ears, Nose, Throat, Mouth: (Hearing loss, chronic nasal congestion, chronic cough)

Yes

Please describe

Respiratory: (Asthma, chronic bronchitis, shortness of breath, etc.)

Yes

Please describe

Cardiovascular (Diabetes, hypertension, heart problems, etc.)

Yes

Please describe

Gastrointestinal (diarrea, constipación, hernia, ulcers, etc.)

Yes

Please describe

Genitourinary (Painful urination, frequent urination, jaundice, etc.)

Yes

please describe

Hematological/Lymphatic (Anemia, bleeding problems, etc.)

Yes

Please describe

Musculoskeletal (Muscle Pain, trauma, osteoarthritis, osteoporosis, etc.)

Yes

Please describe

Skin (Eczema, Psoriasis, rases etc.)

Yes

Please describe

Neurological (Epilepsy, Cerebral Palsy, tumor, etc.)

Yes

please describe

Psychiatric (ADHD, Depression, anxiety, etc.)

Yes

Please describe

Endocrine (Diabetes, Thyroid problem, etc.)

Yes

Please describe

Allergic/Immunological

Yes

Please list all food, environmental, and medication allergies

Personal Medical History

Please List all current medications:

Does the patient have any of the following illnesses or conditions (Please check and describe in the list below):

Description of Above or other:

Does the patient have any of the following eye conditions (Please check and describe in the list below)?

None

Glaucoma

Blindness

Retinal Detachment

Cataracts

Strabismus

Macular Degeneration

Amblyopia

Description of Above or other:

Family Medical History

Check each one Yes or No to indicate of any member of your family has had these diseases. Family history includes your parents, grandparents, siblings, and your children.

Blindness

Yes

Relationship to Patient

Cataract

Yes

Relationship to Patient

Macular Degeneration

Yes

Relationship to Patient

Glaucoma

Yes

Relationship to Patient

Retinal Detachment

Yes

Relationship to Patient

Lupus

Yes

Relationship to Patient

Strabismus (eye turn or crossed eyes)

Yes

Relationship to Patient

Amblyopia (Lazy Eye)

Yes

Relationship to Patient

Dyslexia (or other reading problems)

Yes

Relationship to Patient

High Blood Pressure

Yes

Relationship to Patient

Heart Disease

Yes

Relationship to Patient

Thyroid Disease

Yes

Untitled

Diabetes

Yes

Relationship to Patient

Cancer

Yes

Relationship to Patient and type:

Other:

Yes

Relationship to Patient

Social History

Please answer the following questions (for young children you can select N/A):

Do you currently or have you in the past used tobacco products?

Yes

N/A

please describe the types of tobacco products, the amount of use, and if you are no longer using them, what year you quit using them.

Please describe your alcohol consumption (how many days per week you drink and how many drinks you have in an average week)?(for young children you can write N/A):

If you use them, please describe your use of Recreational/Street drugs (How long you have taken them, what type, the amount taken, and the frequency of taking them)?

Female: Are you pregnant?

Yes

N/A

how many months pregnant are you?

Patient lives with:

Both Parents

Single Parent

Guardian

Who else lives at home with the child:

Siblings

Others

Number of children at home :

Is the patient exposed to second hand smoke?:

Yes

Visual Signs/Symptoms Checklist

Name

First Last

DOB :

READING AND WORK

SPORTS, COORDINATION

Accident Prone

Poor Coordination

Poor Balance

Dislikes sports/physical activities

Poor performance in sports/physical activities

Poor Rhythm and timing

Poor depth perception

VISUAL PERCEPTION

Visual Discrimination

Difficulty seeing the difference between two similar letters, shapes, or objects

With math, omits/confuses steps or function signs (+, -, x, ÷, <, >)

Reverses Letters/Words

Confuses words

Visual Figure-Ground

Difficulty finding a specific piece of information on a page or in a situation

Difficulty with getting “lost in the details”

Easily frustrated or fatigues quickly with too much print on a page

Visual-Motor Processing Issues

Difficulty with visually guided motor activities

Poor handwriting

Difficulty writing within the lines or margins

Difficulty copying from a book or a whiteboard

Frequently drops utensils or knocks over drinks

Form Constancy Issues

Difficulty recognizing letters, words, or numbers, especially if the size, font, or color changes

Confuses lefts and rights

Difficulty recognizing the same objects in different situations.

Difficulty recognizing letters, words, or numbers, especially if presented differently (i.e., paper, book, or board)

Difficulty building or putting together something from a set of instructions

Visual Closure

Difficulty identifying an object when only parts are visible (example: truck but missing wheels, or a person if missing facial features)

Difficulty with spelling or reading because they can’t recognize a word if a letter is missing

Visual-Spatial Issues

Difficulty telling where objects are in space

Difficulty with depth perception or judging how far things are from them and from each other

Poor balance or coordination

Difficulty with crowding when writing

Difficulty with telling time, reading maps, and/or judging time

Often trip, falls, or bumps into things

Prone to getting lost

Long- or Short-Term Visual Memory Issues

Difficulty recalling what has been seen

Difficulty with recognizing familiar words either recently or from page-to-page

Difficulty with spelling familiar words or words they have practiced many times

Difficulty remembering what they have read

Difficulty using a keyboard or calculator

Visual Sequencing Issues

Difficulty telling the order of symbols, words or images

Difficulty in writing answers on a separate sheet

Difficulty remembering sequences, step-by-step instructions, or understanding concept of “first, next, last”

Long Lasting (Chronic) Condition

Chronic health problems

Light sensitivity

General fatigue

Blurry vision that comes and goes

Headaches

Weight loss

Eye pain

Hormone imbalance

Digestion

Recent (Acute) Condition

Head trauma recent

Eye pain

Stroke Motion sickness

Fevers Vertigo

Headaches Recent trauma

Pain Sinus infections

Double vision Ear infections

Excess Condition

Uncoordinated

Lazy eye

Tunnel vision

Mental sluggishness

Head tilt/turn

Asthma

Double vision

Weight gain

Eye turn in

Emotional Fatigue

Reactive Condition

Emotional/Post-traumatic Condition

RELEASE OF INFORMATION:

IT IS OFTEN BENEFICIAL TO US TO DISCUSS EXAMINATION RESULTS AND TO EXCHANGE INFORMATION WITH OTHER HEALTH CARE PROFESSIONALS INVOLVED IN YOUR CARE. PLEASE SIGN BELOW TO AUTHORIZE THIS EXCHANGE OF INFORMATION.

I'm the Parent of and undersigned give Eye Therapy, permission to release any Protected Health Care Information regarding my medical records, including diagnosis to other health care professionals, specifically, but not limited to those listed below, when it is necessary for the treatment of my visual condition.

Primary Care Physician/Clinic

Other Doctor/Clinic

Primary Eye Doctor/Clinic

School District

Other Family Member: (Relationship)

Signatures:

Name of the signer below

First Last

Name of the Child

First Last

Parent’s or Guardian’s Signature

Date

Expires on:

End of Treatment

Specific Date

RELATIONSHIP TO PATIENT

Date

INSURANCE – ONLY AN ESTIMATE:

Eye Therapy is willing to provide you with an ESTIMATE of what your insurance will or will not cover. However, we cannot and do not guarantee that the ESTIMATE we provide is correct. When we as the provider or you call in to get the ESTIMATE it is given with the statement “this is not a guarantee of payment”. Please understand that while we will assist you in understanding your benefits, we have no influence over your coverage. You are ultimately responsible for all fees and charges on your account.

I understand that payment in full is due at time of service unless other arrangements have been made.

authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I also give permission for Eye Therapy to release any Medical Records requested by my insurance company for claim processing. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.

Thank you,

I have read and accept this policy,

Patient name

First Last

Responsible party name

First Last

Signature of Parent/Guardian:

Date

STATEMENT OF PRIVACY PRACTICES

Our office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend your privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our vision and medical care operations. Your personal health information will never be otherwise given to anyone, even family members, without your written consent. You, of course, may give written authorization for us to disclose your information to anyone that you choose, for any purpose.

Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information
We will only request personal information needed to provide our standard of quality vision and medical care, implement payment activities, conduct normal optometric practice operations, and comply with the law. This may include your name, address, telephone number(s), social security number, employment data, medical history, and health records. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law

Disclosure of Protected Health InformationAs stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and government officials under certain circumstances. We will not use your information for third party marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments, including voice mail messages, answering machines, postcards, and email.

Patient Rights
You have the right to request copies of your healthcare information and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

HIPAA Privacy Practice Acknowledgment:

I have received or was offered and declined a notice of privacy practices.

Patient Name

First Last

Signature of Parent/Guardian:

Date

RELATIONSHIP TO PATIENT

Name

First Last

DOB :

Date

10-POINT SCALED SYMPTOM SURVEY

On a scale from 0-10 (10 being most severe) how severe are the following symptoms while doing visual tasks?

1 Headaches (In general including frequency and severity)

Score :

Comments :

2 Eye strain, soreness, pain, or discomfort

Score:

Comments :

3 Eyes get tired and generally become tired

Score:

Comments :

4 Double vision, shadowing of letters, words move, jump, swim, appear to float on the page

Score:

Comments :

5 Blurry Vision even though glasses are on or have been told glasses are unnecessary

Score:

Comments :

6 Loss of place, skipping words and/or lines while reading, or have to reread the same line of words

Score:

Comments :

7 Motor Coordination/Difficulties with Depth perception (accident prone, poor hand-eye coordination, avoid or have poor performance in sports, frequently knock things over, trip, fall, or run into things, poor rhythm/timing)

Score:

Comments :

8 Academic Concerns (Poor Interest in reading and school, poor reading comprehension, poor grades, homework takes longer than it should, poor handwriting)

Score:

Comments :

9 Visual Perceptual Difficulties (Letter reversals, confusion with words, letters, numbers, symbols, get lost in details, fatigues or becomes confused with too much info on page, confused with different fonts, poor visual recall)

Score:

Comments :

10 Balance/Dizziness/Vertigo/Disorientation/Nausea?

Score:

Comments :

11 Poor attention, focus, concentration, hyperactivity?

Score:

Comments :

12 Brain fog, sensory overstimulation, motor overload (Unable to think clearly with too much stimulus, overwhelmed with too much light, sound, busy visual environments/patterns, unable to sit still or reflexive movements due to overstimulation)

Score:

Comments :

13 Behavior problems, poor self-esteem/confidence, easily frustrated, anxiety, depression

Score:

Comments :

14 Eye wanders or crosses?

Score:

Comments :

15 Other - please describe: (difficulty with multitasking, auditory processing difficulties, etc.

Score:

Comments :

Number

CHILD HX FORMS PACKET with 10 point symptom survey

Medical Information

Developmental History

Strabismus/Amblyopia (Wandering/Crossed or Lazy Eyes) – Circle all that apply

Review of Systems

Personal Medical History

Family Medical History

Social History

Visual Signs/Symptoms Checklist

VISUAL PERCEPTION

RELEASE OF INFORMATION:

Signatures:

INSURANCE – ONLY AN ESTIMATE:

STATEMENT OF PRIVACY PRACTICES

HIPAA Privacy Practice Acknowledgment:

10-POINT SCALED SYMPTOM SURVEY

Pupila Family Eye & Ear Care

Pupila Family Eye & Ear Care