Step 1 of 3 33% Name* First Last Sex* Male Female DOB* MM slash DD slash YYYY Home Phone*Ethnicity Hispanic Caucasian African American Native American Asian Pacific Islander Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent(s) or Guardian(s)* Adult(s) Occupation* How did you learn about our program? Current patients Referred by friends/family Print ads Radio ads Website Story in newspaper/TV Referred by doctor Name of referring doctor* Eye HistoryHave you ever noticed any of the following happening with your baby's eyes? (please check any that apply) Eye Turn: In Eye Turn: Out Eyes watering Eyes red Swelling around the eyes White appearance in pupil Explain any eye concerns noted by observing child:Developmental and Health History - PregnancyLength of pregnancy (weeks): List any complications during pregnancy:Other pregnancy issues:Developmental and Health History - DeliveryBirth Weight (lbs) Mother's age at time of birth: Father's age at time of birth: List any complications during delivery:Was oxygen used? Yes No APGAR score at birth (if known): Developmental and Health History - MedicalChild's Doctor: Last Exam Date: MM slash DD slash YYYY Are immunizations up to date? Yes No Does your baby have any known food or drug allergies? Yes No Allergy Information:Does your baby take any medications regularly? Yes No List ALL medications taken regularly:List any development delays:Check all of the following that your baby can do at this time: Roll Over Sit Crawl Stand Walk Has your baby ever had a high temperature (fever)? Yes No How high? 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: Family HistoryDo any family members have: Lazy eye (amblyopia) Eye turn (strabismus) Eye tumor Please list any family members with a history of other eye or medical problems.List the relation and type of problem.AcknowledgementI 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.Type Name to Digitally Sign* HiddenSignatureToday's Date* MM slash DD slash YYYY CAPTCHA
