Infant Questionnaire

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home phone number

Area Code Phone Number

Cell phone number

Area Code Phone Number

Date of birth:

Referred by:

Father's name:

Occupation:

Date of birth:

Cell phone:

E-mail

Mother's name:

Occupation:

Date of birth:

Cell phone:

E-mail

Insurance Provider:

Insurance ID#

Primary Insured Name:

Primary Insured date of birth:

Parents, may we add you on Facebook?

If yes, what is your contact name?

Brothers and Sisters	Birthdate	Age	Grade
__________________	____________	__________	__________
__________________	____________	__________	__________
__________________	____________	__________	__________
__________________	____________	__________	__________

Is your baby having any visual difficulties? If so, what kind of difficulties?

Have you ever seen your infant's eyes turn in or out? If yes, when?

Have you ever been told your infant has a "lazy" eye? If yes, by whom?

Does anyone in your family have a lazy eye or a turned eye?

How long has the difficulty been noted?

Does your infant rub his/her eyes?

Are the eyes frequently red?

Was or is your infant breast of bottle fed?

Term of pregnancy:

Normal birth:

Were there any complications before, during or immediately following delivery?

Did you experience illnesses or injuries while pregnant?

What, if any, medications did you take while pregnant?

Was anesthetic used during the birth?

APGAR score:

Infant's birth weight:

Was there any unusual position of your infant's head, face, body or cord at birth?

Did your baby crawl? At what age?

At what age did your infant sit alone? Walk along?

Speech: age when first word was spoken:

Sentences:

Is your infant active?

What circumstances make your infant irritable?

What comforts your infants?

Please list past illnesses including any history or high fevers or significant injuries and the age at which they occurred:

Health at present is:

Good Fair Poor

Is your infant under and medication? if so, what?

Does your infant have any known allergies?

Has your infant been inoculated for DPT?

Name and address of pediatrician:

May we send a report of our findings to your infant's pediatrician?

Yes No

Has your infant been seen previously for a visual examination?

If so, by whom, when, and what was the outcome?

Give a brief description of your infant's personality:

Infant Questionnaire

Present Situation

Developmental History

General Health