Child and Family History FormDateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Email Student's Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gestational Age Birth Weight Multiple BirthSingleTwinsTripletsPast Ocular HistoryYour child’s ocular history (e.g., age of symptoms onset; eye turns; eye surgeries [list and note year]; eye-poking; etc.):Parent description of functional vision (e.g., response to parent’s face; to toys or objects; tracking favorite color; etc.):Eye medications:Any significant family ocular history (eye diseases – eye turns, lazy eye, eye patching, thick glasses, medical problems or disabilities in the family, etc.):Past Medical HistoryPerinatal HistoryMother (e.g., general health of mother during pregnancy; general nutritional status; estimated date of confinement; drugs-alcohol-medications during pregnancy; trauma; multiple births; infections such as CMV, AIDS, toxoplasmosis, maternal rubella; steroid use; hypertension; pre-eclampsia):Your child’s gestational age at birth. Birth weight. Did the baby move in utero? How was the birth? Was resuscitation required? Other congenital anomalies?):Postnatal HistoryNursery Stay (retinopathy of prematurity risk factors, especially low birth weight and exacerbated by several factors including, sepsis, transfusions, unstable course; cortical visual impairment risk factors including above, and history of intraventricular hemorrhage):Current Medical Problems (seizures, trauma, other congenital anomalies; birth marks, ADHD, hearing, speech, hospitalization, frequent visits to the doctor, surgeries-[please list and note date of], other diagnosis, etc.):Developmental History: When did your child raise his/her head? Crawl? Walk? Reach/grasp object – when?Medications:Allergies:Educational Issues: How is your child performing in early intervention services/school? Explain type of home/school s/he participates in or attends?Other Interventions: What services Is your child receiving (e.g., occupational or physical therapy, speech therapy, services from a teacher of the blind or visually impaired, orientation or mobility, etc.)?Lawrence, L. M. (2003). Pediatric Low Vision. Project ORBIS International Inc. http://telemedicine.orbis.org/bins/volume_page.asp?cid=1-861-863-862&lang=1 Hatton, D.D., & Campbell, A.F. (2003). Interpreting eye reports. Chapel Hill, NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.