(661) 775-1860

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(661) 775-1860

Home New Patient Forms Child Online Questionnaire

Child Online Questionnaire

Please check one of the following:

Appointment with: Dr. Carl Garbus Dr. Danielle Benosa

Appointment Date

Appointment Time

How did you hear about our office

If referred by professional, please select type

Name of Referral

Referral's Phone Number

General Information

First Name

Last Name

Birth Date

Gender Male Female

Street Address (with apartment #)

City

State

Zip Code

Name of Parent 1/Caretaker

Parent 1/Caretaker's Business Phone Number

Parent 1/Caretaker's Cell Phone Number

Parent 1/Caretaker's Email Address

Name of Parent 2/Caretaker

Parent 2/Caretaker's Business Phone Number

Parent 2/Caretaker's Cell Phone Number

Parent 2/Caretaker's Email Address

Vision Care Insurance

Name of Subscriber

Last 4 Number of Social Security of Subscriber

Birth Date of Subscriber

Sibling(s) and age(s)

Name and address of school

Grade

Teacher(s)

Is your child especially afraid of doctors? Yes No

Child's dominant hand Right Left

Has guidance been given in use of hand? Yes No

Patient History

Medical History

Pediatrician's Name

Date of Last Evaluation

For what reason?

Results and recommendations

Child's current state of health

Medications and/or Vitamins with Dosage and Reason

Allergies

Surgical History

Has your child experienced any reactions to immunizations? Yes No

If yes, please explain

List illnesses, bad falls, high fevers, etc.

Are there any chronic problems like ear infections, asthma, hay fever, or allergies? Yes No

Please list

Has a neurological evaluation been performed? Yes No

By whom?

Results and recommendations

Has as psychological evaluation been performed? Yes No

By whom?

Results and recommendations

Has an occupational therapy evaluation been performed? Yes No

By whom?

Results and recommendations

Vision History

Has your child complained about any of the following issues?

Loss of Vision Yes No

Explain

Blurred Vision Yes No

Explain

Distorted Vision/Halos Yes No

Explain

Loss of Side Vision Yes No

Explain

Dryness Yes No

Explain

Mucous Discharge Yes No

Explain

Redness Yes No

Explain

Sandy or Gritty Feeling Yes No

Explain

Itching Yes No

Explain

Burning Yes No

Explain

Excess Tearing/Watering Yes No

Explain

Glare/Light Sensitivity Yes No

Explain

Eye Pain or Soreness Yes No

Explain

Chronic Infection of Eye or Lid Yes No

Explain

Sties or Chalazion Yes No

Explain

Flashes/Floaters in Vision Yes No

Explain

Tired Eyes Yes No

Explain

Has your child's vision been previously evaluated? Yes No

Name of Doctor

Date of Last Eye Exam

Reason for Last Exam

Which was prescribed last eye exam? Glasses Contact Lenses Nothing

Are these optical devices being used? Yes No

If yes, for what? If they're not being used, why not?

Why do you feel your child needs a visual evaluation?

How long has this problem/difficulty been observed?

Contact Lens Policy: If you are requesting a contact lens prescription, our office provides a full service program – evaluation, fitting, and follow-up. Our office does not release the contact lens prescription until you have been successfully evaluated and fitted.

Family History

If anyone in the family (grandparents, uncles, aunts, cousins, mother, father, and/or siblings) has any of the following conditions, please indicate who. If not applicable, please leave it blank.

Amblyopia

Arthritis

Blindness

Brain Tumor

Cancer

Cataracts

Chromosomal Imbalance

Cornea Problems

Corneal Transplant

Crossed/Lazy Eye

Detached Retina

Diabetes

Epilepsy/Seizures

Glaucoma

Heart Problems

High Blood Pressure

Keratoconus

Kidney Problems

Learning Disability

Macular Degeneration

Multiple Sclerosis

Strabismus (Eye Turn)

Stroke

Tuberculosis

Thyroid Condition

Traumatic Brain Injury

Nutritional Information

Current Diet Excellent Good Fair Poor

Does your child like or crave sweets? Like Crave

What types?

Is your child active? Yes No

Moderately or extremely active? Moderately Extremely

Are there periods of very high energy? Yes No

Are there periods of very low energy? Yes No

Explain

Developmental History

Full-term pregnancy? Yes No

Did the mother experience any health problems during the pregnancy? Yes No

Explain

Were there any complications before, during, or immediately after delivery? Yes No

Explain

Birth weight:

Apgar scores at birth:

Apgar scores after 10 minutes:

Were forceps used? Yes No

Was there ever any reason for concern over your child's general development? Yes No

Explain

Was early speech clear to others? Yes No

Is speech clear now? Yes No

List the age at which your child could do the following. If unable, mark with N/A.

Responsive smile

Crawl

Roll Over

Creep (Stomach on floor)

Sit up alone

Respond to words and names

Say single words

Say first name

Stack blocks

Walk alone

Scribble spontaneously

Kick a ball

Walk up steps with help

Use two word sentences

Become toilet trained

Put on some clothing alone

Television Viewing/Leisure Time Activities

What are some hobbies or sports your child engages in?

Does your child watch TV? Yes No

If yes, how often?

What is their viewing distance?

Are there any activities your child would like to participate in, but does not? Yes No

Explain

School

Only complete this section if your child has starting schooling.

Age at the time of entrance to Pre-school

Age at the time of entrance to Kindergarten

Age at the time of entrance to First Grade

Does your child like school? Yes No

Specifically describe any difficulties at school:

Has your child changed schools often? Yes No

If yes, when?

Has a grade been repeated? Yes No

If yes,which and why?

Does your child seem to be under tension or pressure when doing school work? Yes No

Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No

If yes, when and how long?

If yes, where and from whom?

If yes, what were the results?

Does your child like to read? Yes No

What does your child read?

What is your child's attitude toward reading, school, his/her teachers, and peers?

Are there any behavior problems at school? Yes No

If yes, what?

Your child's overall school work is: Above Average Average Below Average

Which subjects are above average?

Which subjects are average?

Which subjects are below average?

Does your child need to spend a lot of time/effort to maintain this level of performance? Yes No

How much time on average does your child spend each day on homework assignments?

To what extent do you assist your child with homework?

Do you feel your child is achieving up to potential? Yes No

Does your child's teacher(s) feel your child is achieving up to potential? Yes No

General Behavior

Are there behavior problems at home? Yes No

If yes, what are they?

What is your child's reaction to fatigue?

What is your child's reaction to tension?

Does your child say and/or do things impulsively? Yes No

Is your child in constant motion? Yes No

Can your child sit still for long periods of time? Yes No

Family and Home

Who does your child live with?

Does your child spend time with any other person, not in the home? Yes No

If yes, please explain.

Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)? Yes No

If yes, at what age?

Does you child seem to have adjusted? Yes No

Was counseling/therapy undertaken? Yes No

If yes, is it on-going? Yes No

Is family life stable at this time? Yes No

If no, please explain

How does your child get along with parents/other caretakers?

How does your child get along with siblings?

How does your child get along with playmates at home?

Do any, or did any, of the other children in the family have learning problems?

Give a brief description of your child as a person:

Lifestyle Checklist

Please assign a value between 0 and 4 for each symptom. 0 is Never or Non-existent, 1 is Occasionally, 2 is Often, 3 is Frequently, 4 is Always.

Blurred Vision

Double Vision

Eyes Hurt

Eye Fatigue

Headaches associated with near work

Words run together when reading

Burning, stinging, watery eyes

Falling asleep when reading

Frequent eye rubbing

Eye(s) frequently reddened

Skipping or repeating lines when reading

Words move around on page when reading

Dizziness or nausea associated with near work

Head tilt or closing one eye when reading

Difficulty copying from board

Avoidance of reading and near work

Omitting small words when reading

Writing uphill or downhill

Misaligning digits in columns of numbers

Reading comprehension declining over time

Inconsistent/poor sports performance

Holding reading material too close

Short attention span

Difficulty completing assignments in reasonable time

Saying "I can't" before trying

Avoiding sports and games

Difficulty with hand tools (i.e. scissors. screwdrivers, calculators, keys)

Reverses letters or words

Tendency to knock things over on desk or table

Motion sickness/car sickness

Difficulty with time management

Difficulty with money concepts and/or making change

Misplaces or loses papers/objects, forgetful, poor memory

Reads Slowly

Uses finger as marker to read

Bothered by light

Frequent Blinking

Confuses Right and Left

Sucks thumb

Glum, sulky, moody, bad temper

Photos/Dilation Consent Yes, I would like to have the photos taken of the internal part of my eye and understand that there is an ADDITIONAL CHARGE of $39 No, I do not want to have the photos taken and understand that the dilation may be necessary

48 Hour Cancellation Policy I have read, understand, and agree to abide by the policy above.

Please do not submit any Protected Health Information (PHI).

Location

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Family Vision Care Optometry INC.

Contact Information

Phone: (661) 775-1860

Fax: (661) 775-9627

Email: customercare@fvcoptometry.net

Address

28089 Smyth Dr
Valencia, CA 91355

Hours of Operation

Monday

09:00 am - 06:00 pm

Tuesday

09:00 am - 06:00 pm

Wednesday

09:00 am - 06:00 pm

Thursday

09:00 am - 06:00 pm

Friday

09:00 am - 06:00 pm

Saturday

Closed

Sunday

Closed

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