Children Vision Questionnaire CHILDRENS VISION QUESTIONNAIRE - EXTENDED Appointment: DayDate MM slash DD slash YYYY Time : HH MM AM PM AM/PM Patient's Name: First Last PhoneGENERAL INFORMATIONWere you referred to our office? Yes No If yes whom may we thank for this referral?Birth Date MM slash DD slash YYYY Age - YearsMonthsName of schoolAddress of school Street Address City State / Province / Region ZIP / Postal Code GradeTeacherSchool Nurse:PrincipalIs your child especially afraid of doctors?Child's dominant hand Right Left Has guidance been given in use of hand? Yes No Please list the names and birth dates of your family:Father/CaretakerBirth DateMother/CaretakerBirth DateSiblingBirth DateSiblingBirth DateSiblingBirth DateSiblingBirth DateRESPONSIBLE PERSON INFORMATIONHome Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneFather/Caretaker's Occupation:Business Phone:Business Address: Street Address City State / Province / Region Mother/Caretaker's Occupation:Business Phone:Business Address: Street Address City State / Province / Region ZIP / Postal Code Do you have Major Medical Insurance? Yes No If so, who is the carrier?Policy #Name of Insured: First Last Social Security Number:Driver's License #:MEDICAL HISTORYPediatrician's Name:Date of Last Evaluation:For what reason?Results and recommendations:Child's current state of health:Medications currently using, including vitamins and supplements:For what condition(s)?Immunizations child has received:Immunization type:Date MM slash DD slash YYYY Immunization type:Date MM slash DD slash YYYY Immunization type:Date MM slash DD slash YYYY Immunization type:Date MM slash DD slash YYYY Any reactions to immunization(s) Yes No If yes, explain:List illnesses, bad falls, high fevers, etc.:AgeSevereMildAgeSevereMildAgeSevereMildComplications:Is your child generally healthy? Yes No If no, explain:Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No If yes, please listHas a neurological evaluation been performed? Yes No By whom?Results and recommendations:Has a psychological evaluation been performed?By whom?Results and recommendations:Has an occupational therapy evaluation been performed? Yes No By whom? Results and recommendations:Is there any history of the following? (please check if there is a history)Diabetes Patient Family Who"Cross" or 'Wall" eye Patient Family WhoChromosomal Patient Family WhoImbalance Patient Family WhoGlaucoma Patient Family WhoHigh Blood Pressure Patient Family WhoLearning Disability Patient Family WhoAmblyopia (lazy eye) Patient Family WhoMultiple Sclerosis Patient Family WhoEpilepsy or Seizures Patient Family WhoOtherIf other, please explain:NUTRITIONAL INFORMATIONCurrent Diet: Excellent Good Fair Your child likes Sweets Crave sweets Is your child active? Yes No Moderately? Yes No Extremely? Yes No Are there periods of very high energy? Yes No Are there periods of very low energy? Yes No Explain:DEVELOPMENTAL HISTORYFull-term pregnancy? Yes No Did the mother experience any health problems during the pregnancy? Yes No If yes, explain:Normal birth? Yes No Any complications before, during or immediately following delivery? Yes No If yes, explain:Birth weight:Apgar scores @ birth:After 10 minutes:Were forceps used? Yes No Was there ever any reason for concern over your child's general growth or development? Yes No If yes, why?Did your child crawl (stomach on floor)? Yes No At what age?Did your child creep (on all fours)? Yes No At what age?If not, describe:At what age did your child walk?Was the child active? Yes No Speech: First words:At what age:Was early speech clear to others? Yes No Is speech clear now? Yes No VISUAL HISTORYHas your child's vision been previously evaluated? Yes No If yes, Doctor's Name:Date of last evaluation: MM slash DD slash YYYY Reason for examination:Results and recommendations:Were glasses, contact lenses, or other optical devices recommended? Yes No If yes, what?Are they used? Yes No If yes, when?If not used, why not?Members of the family who have had visual issues and the reason:NameAgeVisual SituationNameAgeVisual SituationNameAgeVisual SituationPRESENT SITUATIONWhy do you feel your child needs a visual evaluation?How long has this problem/difficulty been observed?Is there any evidence from the school, psychologist, or other tests that indicates some visual malfunction may be present? Yes No Does your child report any of the following:Headaches Yes No If yes, when?Blurred vision / focus goes in and out Yes No If yes, when?Double vision Yes No If yes, when?Eyes hurt Yes No If yes, when?Eyes tired Yes No If yes, when?Words move around on the page Yes No If yes, when?Motion sickness/car sickness Yes No If yes, when?Dizziness Yes No If yes, when?List any other complaints your child makes concerning his/her vision:HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING:Eyes frequently reddened Yes No If yes, when?Frequent eye rubbing Yes No If yes, when?Frequent styes Yes No If yes, when?Light sensitivity Yes No If yes, when?Frequent blinking Yes No If yes, when?Closing or covering one eye Yes No If yes, when?Difficulty seeing distant objects Yes No If yes, when?Head close to paper when reading or writing Yes No If yes, when?Avoids reading Yes No If yes, when?Prefers being read to Yes No If yes, when?Tilts head when writing Yes No If yes, when?Tilts head when reading Yes No If yes, when?Moves head when reading Yes No If yes, when?Confuses letter or words Yes No If yes, when?Reverses letter or words Yes No If yes, when?Confuses right and left Yes No If yes, when?Skips, rereads or omits words Yes No If yes, when?Loses place while reading Yes No If yes, when?Vocalizes when reading silently Yes No If yes, when?Reads slowly Yes No If yes, when?Uses finger as a marker Yes No If yes, when?Poor reading comprehension Yes No If yes, when?Comprehension decreases over time Yes No If yes, when?Writes or prints poorly Yes No If yes, when?Writes neatly but slowly Yes No If yes, when?Does not support paper when writing Yes No If yes, when?Awkward or immature pencil grip Yes No If yes, when?Frequent erasures Yes No If yes, when?Tires easily Yes No If yes, when?Difficulty copying from chalkboard Yes No If yes, when?Difficulty recognizing the same word on a different page Yes No If yes, when?Difficulty with memory Yes No If yes, when?Remembers better what he/she hears than sees Yes No If yes, when?Responds better orally than by writing Yes No If yes, when?Seems to know material, but does poorly on tests Yes No If yes, when?Dislikes/avoids near tasks Yes No If yes, when?Short attention span / loses interest Yes No If yes, when?Poor large motor coordination Yes No If yes, when?Poor fine motor coordination Yes No If yes, when?Difficulty with scissors / small hand tools Yes No If yes, when?Dislikes/avoids sports Yes No If yes, when?Difficulty catching/hitting a ball Yes No If yes, when?TELEVISION VIEWING/LEISURE TIME ACTIVITIESDoes child watch TV?How much?How often?Viewing distance?Does your child spend time using computer/video games? Yes No How much?How often?Viewing distance?What other activities occupy your child's leisure time?Are there any activities your child would like to participate in, but doesn't?Please explain:SCHOOLAge at time of entrance to: PreschoolKindergartenFirst GradeDoes your child like school? Yes No Specifically describe any school difficulties:Has your child changed schools often? Yes No If yes, when?Has a grade been repeated? Yes No If yes, which and why?Does your child seem to be under tension or extreme pressure when doing school work? Yes No Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No If yes, when?Where and from whom?How long?Results:Does your child like to read? Yes No Voluntarily? Yes No Does your child read for pleasure? Yes No What does your child read?What is your child's attitude toward reading, school, his/her teachers, other youngsters?Overall schoolwork is: Above average Average Below average WHICH SUBJECTS ARE:Above average:AverageBelow averageDoes your child need to spend a lot of time/effort to maintain this level of performance? Yes No How much time on average does your child spend each day on homework assignments?What extent do you assist your child with homework?Do you feel your child is achieving up to potential? Yes No Does the teacher feel your child is achieving up to potential? Yes No GENERAL BEHAVIORAre there any behavior problems at school? Yes No If yes, what?Are there any behavior problems at home? Yes No If yes,. what?Child's reaction to fatigue? Sad Irritable Other If other, please explainChild's reaction to tension? Avoidance Irritable Other Does your child say and/or do things impulsively? Yes No Is your child in constant motion? Yes No Can your child sit still for long periods? Yes No FAMILY AND HOMEPlease indicate which adult(s) he/she lives with? Mother Father Stepmother Stepfather Foster Parents Adoptive Parents Grandmother Grandfather Does your child spend time with any other person, not in the home? Yes No Please explain:Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)? Yes No If yes, at what age:Does your child seem to have adjusted? Yes No Was counselling/therapy undertaken? Yes No If yes, is it ongoing?Is family life stable at this time? Yes No If no, please explain:How does your child get along with:Parents/other caretakers?SibIings?Classmates in school?PIaymates at home?Did father or anyone in father's family have a learning problem? Yes No If yes, who?Did mother or anyone in mother's family have a learning problem? Yes No If yes, who?Do any, or did any, of the other children in the family have learning problems? Yes No If yes, who? To what extent?GIVE A BRIEF DESCRIPTION OF YOUR CHILD AS A PERSON:THERE ANY OTHER INFORMATION YOU FEEL WOULD BE HELPFUL/IMPORTANT IN OUR TREATMENT OF YOUR CHILD? Δ
