Andrea Kropf OD - Pediatric Medical Form

Date

MM / DD / YYYY

Name

First Last

Date of Birth

MM / DD / YYYY

Was your child premature?

Yes

No

If Yes, How many Weeks

Birth Weight

Any problems with pregnancy/delivery?

Yes

No

Has your child worn bifocals?

Yes

No

Does your child wear glasses?

Yes

No

Does your child's eye turn in/out?

Yes

No

Does your child have a head tilt?

Yes

No

Has your child ever worn an eye patch?

Yes

No

Does your child wear contact lenses?

Yes

No

Has your child ever had eye surgery?

Yes

No

If yes what type?

Does your child have any developmental delays?

Yes

No

If yes what type?

Does your child have any problems with any of the following?

List any medical conditions

List any surgical procedures

List any medications your child is taking

List any allergies to medication

Does your child attend school?

Yes

No

Does your child have difficulty learning?

Yes

No

Is your child in special education?

Yes

No

Does any member in your child's family (including grandparents) have any of the following?

Amblyopia

Strabismus

Lazy Eye

Glaucoma

Macular Degeneration

Is your child adopted?

Yes

No