InfantSEE: History Form

Have you ever noticed any of the following happening with your baby's eyes?

• Pregnancy
  • Length of Pregnancy weeks
  • Any Complications?
    
  • Other pregnancy issues:
    

• Delivery:
  • Birth Weight: lbs.
  • Parents Ages at Time of Birth: Father: Mother:
  • Any Complications during delivery?
    
  • Was oxygen used? Yes No
  • APGAR score at birth (if known):

• Medical:
  • Child's Doctor:
  • Last Exam Date:
  • Are immunizations up to date? Yes No
  • Does your baby have any known food or drug allergies?
    
  • List all medications taken regularly:
    
  • List any developmental delays:
    
  • Check all of the following that your baby can do at this time:
    Roll Over
    Sit
    Crawl
    Stand
    Walk
  • If your baby has ever had a high temperature, how high was it? Degrees Farenheit
  • Please list any illnesses your baby has had:
    (include age and severity- mild, moderate, severe)
    
  • List any accidents, eye, or head injuries, and the age they occurred:
    
  • Please list any other conditions we should know about:
    

• Do any family members have:
  

  Lazy Eye (amblyopia)	Yes No
  Eye Turn (strabismus)	Yes No
  Eye Tumor	Yes No

• Please list any family members with a history of other eye or medical problems. List relation and type of problem: