Child Vision and Eye Health History Form

Sex*
Please indicate your child's sex.

Date of Birth*
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Child's First Name*
Please enter your child's first name.

Child's Initial
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Child's Last Name*
Please enter your child's last name.

Address 1*
Please enter your address.

Address 2
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City*
Please enter your city.

Postal Code*
Please enter your postal code.

Parent Name(s)*
Please enter the parent name(s).

Parent Home Phone*
Please enter your home phone number.

Parent Work Number
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Parent Cell Phone
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Parent Email Address*
Please enter a valid email address.

Health Card #*
Please enter your child's health card number.

Health Card Version Code
Please enter the health card version code.

Note: Version code is the two letters after the OHIP # and is not present on all cards.

Health Card Expiry Date
Please enter the health card expiry date.

Note: Not present on all cards.

Reason for today's visit
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Child's Personal History
Appears to have crossed or lazy eye
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Complaints of blurred or double vision
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School/Parent suspects a vision problem
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School has identified a reading problem
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Allergies (drug or other)
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Please list
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Taking any medications
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Please list
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Other pertinent history or comment
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Pregnancy was considered
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Any serious eye or general health problems at birth?
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Please explain
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Family Eye History
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Other - please elaborate
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Family General Health History
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Other - please elaborate
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Date of last eye examination
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By Dr.
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Date of last medical examination
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By Dr.
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Date of last dental examination
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By Dr.
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Would you like a report sent to your child’s physician?
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Family Physician’s Name
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Physician's Phone Number
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Security Code*
Security Code
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