Infantsee Form

STEP 1

Name *

Sex *

Date Of Birth *

Home Phone *

Ethnicity

Home Address *

State

Parent(s) or Guardian(s) *

Adult(s) Occupation *

How did you learn about our program?

STEP 2

Developmental and Health History - Pregnancy

Have you ever noticed any of the following happening with your baby's eyes? (please check any that apply)

Explain any eye concerns noted by observing child:

Developmental and Health History - Pregnancy

Length of pregnancy (weeks):

List any complications during pregnancy:

Other pregnancy issues:

Developmental and Health History - Delivery

Birth Weight (lbs)

Mother's age at time of birth:

Father's age at time of birth:

List any complications during delivery:

Was oxygen used?

APGAR score at birth (if known):

Developmental and Health History - Delivery

Child's Doctor:

Last Exam Date:

Are immunizations up to date?

Does your baby have any known food or drug allergies?

Does your baby take any medications regularly?

List any development delays:

Check all of the following that your baby can do at this time:

Has your baby ever had a high temperature (fever)?

Please list any childhood illnesses your baby has had:
Include the type of illness, age at the time, and whether the illness was mild, moderate, or severe.

List any accidents, eye, or head injuries, and age they occurred:

Please list any other conditions we should know about

STEP 3

Family History

Do any family members have:

Please list any family members with a history of other eye or medical problems.
List the relation and type of problem.

Acknowledgement

I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of my child's eyes and vision. I understand that the InfantSEE™ vision assessment is without charge. If further services or treatments are recommended, I may choose any eye professional to provide those services.

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