Scituate Harbor Vision Source
Secure Form
Pediatric Registration
Step
1
of
2
50%
Welcome to the office of Jessica Crooker, Jung Chan, Melissa Andrade, and Rebecca Posner Doctors of Optometry
Name
*
First
Last
Date of Birth
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Mobile / Cell Phone
Email
Enter Email
Confirm Email
Guarantor's Name
Medical Insurance
Medical Insurance ID#
Vision Insurance
Vision Insurance ID#
Referred By
Check Preference
I approve of a report summarizing my son's or daughter's vision evaluation being sent to his or her primary care physician or referring specialist.
Please do not send information to a physician or specialist without my written consent.
Ocular History
Reason for examination
Last Eye Exam
When and where was your last eye exam?
Does He or She Wear Glasses?
Yes
No
When?
Near Tasks
Distance Tasks
Full-Time
Does He or She Wear Contacts?
Yes
No
Interested In Getting Contacts?
Yes
No
Type?
Does Your Child Have Any of the Following
Blurred Vision
Double Vision
Squints Frequently
Poor Tracking / Eye Movements
Loses Place While Reading
Eye Turn / Head Tilt / Face Turn
Amblyopia
Loss of Central Vision / Side Vision
History of Eye Injury / Surgery
Frequent Headaches
Nystagmus
Rubs Eye / Itchy
Burning / Tearing Eyes
Red Eyes / Discharge
Eye Pain / Tired Eyes
Light Sensitivity
Other
Other
Please explain above
Medical History
How long was the pregnancy?
In months
Any complications during pregnancy or delivery?
Yes
No
Explain
Has your child undergone any of the following testing / treatment?
Educational
Occupational
Neurological
Speech
Psychological
Physical
Explain Above
Primary Care Physician
Last Medical Exam
Please list any current medications
Please list any allergies to medications
Please list any major surgeries or injuries
Approximate Weight
Approximate Height
Does your child have any of the following?
Allergies (medications, antibiotics, pollen, mold)
Yes
No
Explain
Cardiovascular / Heart Problems (hypertension)
Yes
No
Explain
Constitutional (excessive weight loss, dizziness)
Yes
No
Explain
Endocrine Problems (thyroid disease, diabetes)
Yes
No
Explain
Gastrointestinal Problems (hepatitis, colitis)
Yes
No
Explain
Urinary Problems (sexually transmitted disease)
Yes
No
Explain
Ear/Nose/Throat Problems (hearing loss, dry mouth)
Yes
No
Explain
Blood Disease (anemia, temporal arteritis, sickle)
Yes
No
Explain
Immunological (lyme disease, HIV, AIDS, herpes)
Yes
No
Explain
Skin (psoriasis, rashes, dermatitis, rosacea)
Yes
No
Explain
Musculoskeletal Problems (rheumatoid arthritis)
Yes
No
Explain
Neurological (seizures, migraines, dyslexia)
Yes
No
Explain
Psychiatric / Social Problems (depression, ADD)
Yes
No
Explain
Breathing Problems (asthma, sarcoidosis)
Yes
No
Explain
Cancer (colon cancer, melanoma)
Yes
No
Explain
Other
Family History
Does anyone in your immediate family have any of the following?
Amblyopia / Lazy Eye
Blindness
Cataracts (before 40 years old)
Macular Degeneration
Retinal Detachment
Eye Turn / Strabismus
Glaucoma
Other Eye Disease
Color Blindness
Genetic / Familial Disorders
Cancer
Diabetes
Elevated Cholesterol
High Blood Pressure / Heart Problems
Thyroid Disease
Other
Other
Social History
Do you drive?
Yes
No
Do you use tobacco products?
Yes
No
Hobbies?
Sports?
I authorize payment of benefits directed to Dr. Jessica Crooker, Dr. Jung Chan, Dr. Melissa Andrade, and Dr. Rebecca Posner for services rendered. I also authorize release of any medical information that may be required in determination of such benefits. I understand that some services may require approval of my child's primary care physician for coverage and that, if I don't obtain that approval, I am financially liable for the services. I understand that my insurance carrier may not cover some services and products and benefit information does not constitute approval of payment. Deductibles & fee not paid by my insurance carrier will be my responsibility. I acknowledge that I received a copy of Dr. Jessica Crooker, Dr. Jung Chan, Dr. Rebecca Posner, and Dr. Melissa Andrade's "NOTICE OF PRIVACY, HIPAA" policy.
*
Yes
No
Signature
Date
mm/dd/yyyy
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.