Lunch Menu
Events Calendar
Logo for KanLovKids Low Vision Collaboration Clinics, the state of Kansas with a magnifier over a heart; the words KanLovKids Clinic Programs; and the logo for the Kansas State School for the Blind, a flying blue eagle in the middle of a red and yellow sunflower.

Child and Family History Form

Date
Student's Name
Date of Birth

Past Ocular History

Past Medical History

Perinatal History

Postnatal History

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.

Back To Top