Child Information Form Location*-- Select One --AirdrieBridgelandSouth Trail CrossingMacleod TrailPanorama HillsGeneral InformationName First Middle Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Alberta Health Care NumberTelephone No. (Home)Current Grade*School*Parent/Guardian*E-mail address* Does your child currently have optical coverage?* Yes No which companyPlease list the main reason for this visitWhere did you hear about us?Is this your child’s first eye exam?* Yes No with whomAnd when MM slash DD slash YYYY Ocular HistoryDoes your child currently use ? Glasses full-time Glasses part-time Reading glasses Contact Lenses None (please check all that apply)Does your child complain of Blurred vision Double vision Red eyes Itchy eyes Eye strain Headaches (please check all that apply) Has your child ever had to wear an eye patch or do eye exercises? Yes No Has your child ever had eye surgery? Yes No please explain Has your child ever had an eye injury? Yes No please explain Medical History & MedicationWho is your child’s family physician?Date of last medical exam? MM slash DD slash YYYY Were there any complications during labour or at birth of your child?* Yes No please explainHas your child experienced any childhood illness* Yes No please explainPlease list all medications currently being taken and purpose (if any):DrugPurposeDrugPurposeDrugPurposeAllergies(if any)Ocular & Family HistoryOcular & Family History (if so, please check)Turned/lazy eye self mother father grand mother grandfather Retinal Detachment self mother father grand mother grandfather Colour blindness self mother father grand mother grandfather Glaucoma self mother father grand mother grandfather Diabetes self mother father grand mother grandfather Migraine headaches self mother father grand mother grandfather Otherplease indicate Sports & RecreationDoes your child play any competitive sports? Yes No please specifyDoes your child have any specific hobbies or crafts? Yes No please specifyWould you like more information on how sports vision therapy can improve your child’s performance? Yes No Would You Like Additional Information with the Following Anti-reflective lenses Scratch-resistant lenses Thinner/lighter lenses Sunglasses Transition lenses Sports glasses Sports vision therapy Disposable contact lenses OtherThis office is in compliancy with Alberta Privacy Legislation and we will not collect, use, or disclose any personal information without prior consent. All information collected on this form and during the course of the examination are protected. EmailThis field is for validation purposes and should be left unchanged. Δ
