Child History Form

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Provide the Following Information. Required Fields are bold.
Date
Patient's name (minor, age 18 or younger)
Email Address e.g. someone@domain.com	^[_\.0-9a-zA-Z-]+@([_\.0-9a-zA-Z-]+\.)+[a-zA-Z]{2,8}$
Parent's names
Address
Address
City
State/Province
Zip/Postal Code
Home phone	( ^[0-9]+$ ) ^[0-9]+$ - ^[0-9]+$
Work phone	( ^[0-9]+$ ) ^[0-9]+$ - ^[0-9]+$
Who referred you to our office? (name)
How did you hear about us?
Patient's date of birth
Grade in school
Name of parent responsible for account
Parent's Occupation
Parent's social security number	^[0-9]+$ - ^[0-9]+$ - ^[0-9]+$
Name of employer
City
Please list any members of your household who come to our office
Please list any eye problems, medical problems or learning / developmental problems the patient has
Who is the patient's family physician?
Have any blood line relatives had glaucoma, or other loss of sight?	Yes No
Is patient allergic to any medications?	Yes No
If yes, please list
Does patient presently wear glasses?	Yes No
How old are the glasses?
When does he/she wear them?
Does patient presently wear contact lenses?	Yes No
What kind of contact lenses?
If yes, how old are the contacts?
If no, has patient ever worn contacts?
Previous eye doctor
Does patient have vision care insurance?	Yes No
If yes, Name and ID number
Do you have health insurance?	Yes No
If yes, Name and ID number