Pediatric Registration – Scituate Harbor Vision Source

Scituate Harbor Vision Source

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Pediatric Registration

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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 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.