Infantsee Form

Name *

Ethnicity

Home Address *

How did you learn about our program?

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:

Length of pregnancy (weeks):

List any complications during pregnancy:

Other pregnancy issues:

Child's Doctor:

Last Exam Date:

Are immunizations up to date?

List any development delays:

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

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.

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.