Child Patient History

Does your child wear glasses?

Does your child wear contact lenses?

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

Please check any of the following conditions that they have been diagnosed with:

Other Conditions:

Please list any current medications:

Birth History

Were they born?
How were they delivered?
Were forceps used during delivery?
Any complications during pregnancy?
Any complications during birth?
Was an incubator or oxygen used?

Have they met their developmental milestones?

School Aged (if applicable):

Do they:

Enjoy School
Enjoy reading
Enjoy being read to
Read at or above grade level
Comprehend what they read
Reach their potential in school
Print neatly
Reverse letters
Come home from school exhausted
Come home from school with headaches

Our Office Hours


8:30am - 12:00pm
1:00pm - 5:00pm


8:30am - 12:00pm
1:00pm - 5:00pm


8:30am - 12:00pm
1:00pm - 5:00pm


10:00am - 2:00pm
3:00pm - 7:00pm


8:30am - 12:00pm
1:00pm - 5:00pm

Closed Saturday, Sunday and Stat Holidays