Online Forms

Child Patient History

Patient First & Last Name

Date of Birth

Sask Health Card #

Family Doctor

Parent/Guardian Name(s):

Parent Email Address

Parent Phone Number

Name of School

Grade

Does your child wear glasses? Yes No

Does your child wear contact lenses? Yes No

Do you have any concerns with their vision or motor skills? If so, please describe:

Other Conditions:

Please list any current medications:

Were they born?	Prematurely	Full-term	Unknown
How were they delivered?	Vaginally	C-section	Unknown
Were forceps used during delivery?	Yes	No	Unknown
Any complications during pregnancy?	Yes	No	Unknown
Any complications during birth?	Yes	No	Unknown
Was an incubator or oxygen used?	Yes	No	Unknown

Have they met their developmental milestones? Yes No

Do they:

Enjoy School	Yes	No	Sometimes
Enjoy reading	Yes	No	Sometimes
Enjoy being read to	Yes	No	Sometimes
Read at or above grade level	Yes	No
Comprehend what they read	Yes	No
Reach their potential in school	Yes	No	Sometimes
Print neatly	Yes	No	Sometimes
Reverse letters	Yes	No	Sometimes
Come home from school exhausted	Yes	No	Sometimes
Come home from school with headaches	Yes	No	Sometimes

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