Pediatric Encounter Form Patient Name* First Last Date of Birth MM slash DD slash YYYY Patient Nickname Gender Age Social Security #Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred E-Mail Address* Home PhoneRace Parent/Caretaker PhoneOccupation Parent/Caretaker PhoneOccupation VISUAL & OCULAR HISTORYHas your child previously been evaluated by an eye doctor? Yes No Last Eye Exam Date MM slash DD slash YYYY what were the diagnoses and recommendations? Does your child wear glasses Yes No how often? Full Time Distance Only Near Only Does your child wear contact lenses? Yes No Brand Does your child verbalize any problems/complaints about his/her eyes or vision? Yes No explain Any history of the following? (please check all that apply) Lazy Eye (R) Lazy Eye (L) Eye patching Prior glasses wear (discontinued) Ocular surgeries Vision therapy Myopia control (Ortho-K, Atropine, etc.) If yes, please describe what and whenHave you or anyone else ever noticed the following regarding your child? (please check all that apply) Difficulty seeing distant objects Eye turn (In) Eye turn (Out) Rubs eyes excessively Squints while looking at objects Covers or turns to use one eye Red or crusty eyelashes Moves objects very close Tilts head to one side Frequent sties Poor depth perception Eyes in constant motion Skin irritation on the face Seems visually unaware Avoids reading Frequent watery eyes Stumbles over things (clumsy) Poor motor control Blinks excessively Confuses colors Abnormally bothered by lights Droopy eyelids MEDICAL HISTORYPediatrician’s Name ListList any medical DIAGNOSES (physical and psychological) List any current MEDICATIONS, including vitamins and supplements List any ALLERGIES to medications, foods, or materials BIRTH HISTORY Premature Full Term Complications For small children, please describe any delayed developmental milestones (motor skills, speech/language, cognitive/problem solving, social/emotional)REVIEW OF SYSTEMS Does your child have any known history of the following? (check all that apply) Cardiovascular Disease High Blood Pressure High Cholesterol Diabetes Mellitus Thyroid or Gland Disease Asthma Other Respiratory Disease Allergic/Immune Disorder Seasonal Allergies Obesity Lyme or Infectious Disease Blood/Lymph Disorder Ears, Nose, Throat Condition Gastrointestinal Problems Genitourinary Problems Skin Condition Musculoskeletal Problems Chromosomal Abnormality Psychiatric Condition Autism Spectrum Disorder ADHD/ADD Depression/Anxiety Learning Disability Neurological Disorder Migraine Headache Head Injury/TBI Epilepsy or Seizures Use this space to elaborate on any conditions specified aboveFAMILY OCULAR HISTORYPlease indicate the relation of any family member with history of the following (ex: paternal-grandmother)Glaucoma Macular Degeneration Strabismus/Eye Turn Amblyopia/Lazy Eye Cataracts Blindness High Glasses Rx Other Ocular Disease FAMILY MEDICAL HISTORYPlease indicate the relation of any family member with history of the following (ex: paternal-grandmother):Heart Disease High Blood Pressure High Cholesterol Diabetes Thyroid Disease Blood Disorders Multiple Sclerosis Other Disease SOCIAL & ACADEMICSchool Grade Hours of screen time per day How is your child doing in school, generally? Below Average Average Above Average Do they receive special accommodations in school? No Yes IEP 504 Please explainI state that the above is true to the best of my knowledge. Parent/Guardian Signature*Date* MM slash DD slash YYYY
