Dr. Traer G. Caywood | Dr. Rick W. Winward

OPTOMETRY

Child's Name:
Street Address:
City/State/Zip:
Gender: Male Female
Date of Birth: -- mm/dd/yy
SS#:
Occupation:
Last Eye Exam Date: -- mm/dd/yy
Last Eye Exam Location:
Name of Medical Doctor:
Medical Doctor Phone:
Last Medical Exam:
Today's Date: -- mm/dd/yy
Home Phone:
Grade in school:

Which office do you prefer to visit? Provo Springville
FAX:
E-mail:
Head of Household:
Employer:
Emergency Contact:
Emergency Contact Phone:
Were you referred to us? Yes No
By whom?

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Insurance Information

Primary Insurance:
Group:
Policy Holder:
Policy Holder SS#:
Employer of Insured
Secondary Insurance:
Medicaid Part B #:
Policy Holder:
Policy Holder SS#:
Medicaid #:
Policy Holder:
Policy Holder SS#:

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Medical History

Does your child have any seasonal or drug allergies? Yes No  If yes, explain:
List any medications your child takes, including eye drops and over the counter medications:
List all major injuries, surgeries, and/or hospitalizations you have had, including eye surgeries:
Note any of the following that your child currently has or has had:  
Disease/Condition

Yes          No

 Disease/Condition

Yes          No

 Disease/Condition Yes     No
Premature birth

         

Floaters           Retinal Detachment     
Oxygen at birth

         

Double vision           Reading difficulties     
Low birth weight

         

Eye Infection           Lazy Eye/Amblyopia     
Slow development           Frequent styes           Flashes of light     
Previous patching           Eye injury           Extreme nearsightedness     
Turned or Crossed Eyes           Blindness           Other     
Is your child current on all his/her immunizations? Yes No
Which type of eye chart should be used for your child?   Letters     'E' Chart     Pictures
Do you wear glasses? Yes No   If yes, when do you wear them?   Full time     Reading     Computer     Driving
Do you wear contact lenses?Yes No  If yes, what type?  Rigid/Hard   Soft   Bifocal   Toric   Extended wear
   Disposable (brand    How often are they replaced?    Are his/her contacts comfortable? Yes No

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Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Disease/Condition

Yes    No

 Relationship Disease/Condition

Yes    No

 Relationship
High Blood Pressure

   

Retinal Detachment    
Diabetes

   

Crossed/Lazy Eye    
Glaucoma     Macular degeneration    
Cataracts     Extreme nearsightedness     

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Review of Systems
Do you currently, or have you had any problems in the following areas::

System

Yes    No

System

Yes    No
Constitutional (fever, weight loss/gain)

   

Musculoskeletal (arthritis, muscles, bones)    
Eyes

   

Integumentary (skin, breast)    
Ears, Nose, Mouth, Throat     Neurological (headaches, numbness)    
Cardiovascular/Vascular (heart)     Psychiatric (mental, depression, anxiety)    
Respiratory (lungs)

   

Endocrine (diabetes, thyroid)

   

Gastrointestinal (stomach, intestines, liver)

   

Lymphatic/Hematologic (blood, lymph node)

   

Genitourinary (kidneys, urinary/reproductive tract)

   

Allergic/Immunologic (allergies, immune)

   

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Mark any of the following that you would like more information on:

Contact lenses Colored contacts Laser vision correction
Disposable contacts Bifocal contacts Vision and reading problems of children
Contacts for dry eyes No line bifocals Lazy eye
Contact lenses for astigmatism Special lens designs for computer users Light weight glasses and thinner lenses
Lenses for skiing, scuba diving, biking, hunting, or sports