Case History for Children Please be prepared for child’s examination by completing this form and return it with copies of any previous test(s) including psycho-educational evaluations done prior to your child’s appointment.Name of Child First Last Birthdate MM slash DD slash YYYY Mother's Name First Last Birthdate MM slash DD slash YYYY OccupationFather's Name First Last Birthdate MM slash DD slash YYYY OccupationAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneWho is your pediatrician?AddressWhat is the main problem or concern?When does it occur?How often does it occur?How long does it last?Is there a family history of learning problems? Yes No If yes, explain:List any medications your child takes:Developmental HistoryTerm of PregnancyNormal Birth? Yes No If no, explain any complications before, during or immediately following delivery:At what age did your child:crawl?All fours?Sit alone?Walk alone?Say first words?Say sentences?Was speech clear? Yes No Was child active as a baby? Yes No When under stress, is there any pattern of behavior such as thumb sucking or nail biting?Does your child:Have a history of any high fevers? Yes No Have any significant health problems? Yes No Wear glasses? Yes No If so, for what purpose?Become fatigued? Yes No If so, does he/she: Sag? Become excited? Become irritable? Daydream? How many hours/day does he/she watch TV?Play computer games?Eye Health HistoryName of Eye Doctor First Last Date of Last Eye examPlease bring copies of any tests previously done, if available.EmailThis field is for validation purposes and should be left unchanged. Δ