Child Intake Online Form CHILD/YOUTH INFORMATIONName First Last M F Date MM slash DD slash YYYY Health Card # VC Home 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 Home PhoneCell PhoneEmail Address How did you hear about us? When was your last eye exam? Who was the eye doctor? Medical History Autism/ASD/Aspersers ADD/ADHD Developmental Delay Premature Tubes in ears Broken bones Diabetes Asthma Other Please specify List Medication List Allergies Family Eye / Family Medical ProblemsEye History Cataracts Retinal detachment Macular degeneration Colour blindness Turned or wandering eye Eye surgery Dry eye Lazy eye Vision therapy Eye injury Current Appearance or behaviours Red eyes Watering eyes Discharge from eye Rubs eyes Sensitive to light Poor concentration/ easily distracted Angry Depressed Happy Current Symptoms Trouble seeing distance Trouble reading Blur Dry eyes Itchy eyes Tired eyes Burning eyes Double vision Flashes Spots Achy eyes Nausea Dizziness Uses Eye drops Eye Glasses Contact lenses Sunglasses Hot compresses Eye patch Educational HistoryCurrent School / grade Is your child receiving any tutoring, extra help or special classes? Yes No Does your child have an IEP? Yes No Reading Above Grade On Grade Below Grade Loss of place Words move or running together Poor reading comprehension Word reversals Avoids reading Poor, inefficient reading Holds book close Head aches Other Please specify Printing/Writing/Spelling Above Grade On Grade Below Grade Letter reversals Difficulty copying from board Poor Printing Poor cursive writing Poor spelling Other Please Specify Math Above Grade On Grade Below Grade Difficulty with word problems Misaligns numbers Difficulty with addition Difficulty with fractions Difficulty with multiplication Difficulty with geometry Other Please Specify Gym/Sports/Coordination Above Grade On Grade Below Grade Eye-hand difficulty (kicking, throwing, catching) Difficulty with fine motor control (manipulation with hands/fingers) Difficulty with gross motor control (running, hopping) Skipping and rhythm Balance problems Other Please Specify Developmental HistoryWere there any complications with pregnancy or during birth? Yes No please describe Was your child born prematurely? Yes No how soon? Child’s birth weight When did your child begin walking unassisted? When did your child begin toilet training? When did your child begin to say 2-3 word phrases? Any speech problems now or in the past Yes No Does/did your child enjoy and participate in activities such as drawing, colouring, puzzles, block play, etc.? Yes No At Home Habits Has a messy room Has trouble tying their shoes Is typically a messy eater Has difficulty using forks and knives Often forgetful Often clumsy Difficulty following verbal directions Other Necessary Information