Name: Hopkins Eye Center, PA
Address: 3921 S Highway 14, Suite D, Greenville, SC, 29615, US
Telephone: 864-234-5335
Price range: $000 - $300

Date
MM slash DD slash YYYY
Patients Name*
First Last
Date of Birth
MM slash DD slash YYYY
School
Grade
Pediatrician
Referral By Whom
The reason my child is being examined is
- general check up
- other, please explain
When did symptoms start:
Last eye exam was on
MM slash DD slash YYYY
Where
Glasses:
- Yes
- No
Age 1st Worn
Does your child have any of the following:
Eye turns in/out
- Yes
- No
Explain
Squints a lot
- Yes
- No
Explain
Covers/closes one eye a lot
- Yes
- No
Explain
Doesn’t seem to focus
- Yes
- No
Explain
Lacks interest in reading/near activities
- Yes
- No
Explain
Rubs eyes excessively
- Yes
- No
Explain
Eyes burn and itch
- Yes
- No
Explain
Blinks excessively
- Yes
- No
Explain
Reddened or encrusted eyelids
- Yes
- No
Explain
Watery eyes
- Yes
- No
Explain
Eyelid Droop
- Yes
- No
Explain
Poor tracking / eye movements
- Yes
- No
Explain
Head tilt/Face turn
- Yes
- No
Explain
Moves objects very close to look
- Yes
- No
Explain
Double vision
- Yes
- No
Explain
Frequent headaches
- Yes
- No
Explain
Eye pain
- Yes
- No
Explain
Excess light sensitivity
- Yes
- No
Explain
Stares at bright lights or repeatedly
- Yes
- No
Explain
flicks objects in front of face
- Yes
- No
Explain
Stumbles over objects or is clums
- Yes
- No
Explain
Poor motor control
- Yes
- No
Explain
Any eye injury or surgery
- Yes
- No
Explain
Any lazy eye/amblyopia
- Yes
- No
Explain
Any vision therapy/orthoptics
- Yes
- No
Explain
Any patching
- Yes
- No
Explain
Does your child verbalize any problems/ complaints about his/her eyes or vision?
- Yes
- No
If yes, explain
Last medical exam was on
Doctor
Current medications (dose & reason for taking)
Immunizations up to date
- Yes
- No
Any Reactions to Immunizations:
PREGNANCY/ BIRTH HISTORY:
My child is:
- natural
- adopted
- foster
- other
Please specify
Length of pregnancy
- less than 7 mos
- 7- 8 mos
- 8-9 mos
- over 9 mos
During pregnancy of this child, which, if any, of the following occurred
- toxemia
- trauma
- use of alcohol
- injury by fall
- smoking
- use of drugs
- severe illness
- prescribed medication
- little obstetrical care
- other
Please specify
Please explain
Type of delivery
- Natural
- Caesarian
- Forceps/vacuum
- Anesthesia
- other
Please specify
Were there any problems during delivery?
- No
- Yes
explain
Labor during delivery lasted

hours
Child's birth weight

lbs. and ozs
Apgar score

@ 1 min
Apgar score

@ 5 min
Mother’s age at child’s birth
Father’s age at child’s birth
Immediately after birth my child was
- given oxygen
- allergic
- running a fever
- having breathing/feeding problems
- jaundiced
- doing well, requiring no medical treatment
- placed in incubator
- having Rh problems
- placed in neonatal ICU
- other
please specify
Medication prescribed during first year of life
- Yes
- No
If yes, list meds
DEVELOPMENTAL HISTORY
ACTIVITY / AVERAGE AGE

Gross Motor Development

	EARLY	LATE	NORMAL	UNSURE
Head control / 3 Months
Rolled over / 3.5 Months
Sits w/out support / 6.5 Months
Crawl (stomach on floor) / 7 Months
Creep (stomach off floor)/ 8 Months
Pulls self to stand / 8 Months
Walks unaided/alone / 12 Months
Walks backwards / 14 Months
Kicks a ball / 18 Months
Walks up steps with help / 18 Months
Toilet Trained / 24 Months
Put on some clothing alone / 3 years
Rides tricycle / 3 years

Fine Motor Development

	EARLY	LATE	NORMAL	UNSURE
Eye control 180 degrees /3 Months
Reaches/Grasp for object / 4 Months
Neat pincer grasp / 11 Months
Scribbles spontaneously / 15 Months
Stacks/Piles blocks / 18 Months
Eats with a fork/spoon / 24 Months
Copies circle / 3 years

Language Development

	EARLY	LATE	NORMAL	UNSURE
Smiles spontaneously / 1 Month
Responsive smile / 3-4 Months
Responds to words/ names. / 5 Months
Says single words / 12 Months
Refers to self by first name / 18 Months
Combines 2 different words / 18 Months
Says 2 word sentences / 24 Months
Knows full name / 3 Years

How is your child performing as compared to others his/her age
- Above average
- Below average
Were there any difficulties at all in feeding (such as difficulty with sucking, vomiting)?
- Yes
- No
If yes, explain
Any problems with colic?
- Yes
- No
Was there ever any reason for concern over your child’s general growth or development?
- Yes
- No
If yes, why?
Has your child received any special developmental guidance/ assistance?
- Yes
- No
If yes, explain
How many hours daily does your child sleep?
Does your child sleep through the night?
- Yes
- No
If yes, starting at what age
If no, explain
Did your child have a coordinated crawl and creep before he/she walked?
- Yes
- No
Does your child like to draw/color?
- Yes
- No
Is your child learning to read?
- Yes
- No
What things can your child do very well?
What things, if any, are difficult for your child?
What difficulties are your child experiencing in school?
Has your child undergone any of the following testing/treatment?
Educational
- Yes
- No
Occupational
- Yes
- No
Neurological
- Yes
- No
Speech /Auditory
- Yes
- No
Psychological
- Yes
- No
Physical
- Yes
- No
If yes, please list all previous evaluations done on your child
Doctor or Institution
Date
MM slash DD slash YYYY
Type of Evaluation
Results/Treatment/Intervention
Doctor or Institution
Date
MM slash DD slash YYYY
Type of Evaluation
Results/Treatment/Intervention
Doctor or Institution
Date
MM slash DD slash YYYY
Type of Evaluation
Results/Treatment/Intervention
Doctor or Institution
Date
MM slash DD slash YYYY
Type of Evaluation
Results/Treatment/Intervention
Check the appropriate spaces if you have any concerns about the following behavior(s) in your child
- Lack of curiosity
- Thumb-sucking
- Nervous
- Glum, sulky, mood
- Bad temper
- Passive
- Irritable, easily upset
- Restlessness
- Has difficulty separating from parents
- Sleeplessness
- Lethargic, low energy
- Aggressive
- Other
please explain
NUTRITIONAL INFORMATION
Current Diet
MM slash DD slash YYYY
- Nursed
Until age
- Bottle fed
Solid food started at what age
What type?
Are there any food allergies/sensitivities?
- Yes
- No
If yes, what
Does your child
- Like sweets
- Crave sweets
If so, what?
What are his/her favorite foods?
What are his/her disliked/avoided foods?
Activity Level
- High
- Moderate
- Low
Are there periods of very high energy?
- Yes
- No
If so, when
Are there periods of very low energy?
- Yes
- No
If so, when
GIVE A BRIEF DESCRIPTION OF YOUR CHILD AS A PERSON
Is there any other information that would be helpful/important in our evaluation or treatment of your child?
Name of Parent / Guardian
First Last
Name of Parent / Guardian
First Last
Phone
(In case Doctor has questions)
Email
Thank you for carefully completing this questionnaire. This will enable us to perform a more comprehensive evaluation and to better meet your child’s specific visual needs. Please bring toys or books your child enjoys.
~ Thank You ~

Print, fill out and bring the Developmental History Questionnaire to the practice.

PREGNANCY/ BIRTH HISTORY:

DEVELOPMENTAL HISTORY

NUTRITIONAL INFORMATION