Today's Date MM slash DD slash YYYY What is your email?* What is your child's name?* Child's Birth Date* Month Day Year Person completing this form Relationship to child Has the child had a vision exam before? Yes No When was the child's last exam? MM slash DD slash YYYY Does the child wear glasses? Yes No Does the child wear contacts? Yes No Is the child currently taking any medications? Yes No What medications?Has the child had any allergic reactions to medications? Yes No What were they?Is the child currently diagnosed with any medical conditions? Yes No What are they? Has the child ever had any of the following? If yes please explain:Eye surgery Yes No Please explainEye injury Yes No Please explainVision therapy Yes No Please explainHas anyone in the child’s immediate family (parents, siblings) had the following? Strabismus (Eye turns) Yes No Who?Amblyopia (“Lazy eye”) Yes No Who?Childhood Glaucoma Yes No Who?Childhood Cataracts Yes No Who?High Prescription Yes No Who? Is the child 0-5 years old? Yes No HiddenWhat was the length of the pregnancy for this child? What was the child's birth weight? Was oxygen provided to this child? Yes No For how long? CommentsThis field is for validation purposes and should be left unchanged.