ABOUT MY CHILD’S EYES PCHS

Special School Eye Care Service
ABOUT MY CHILD’S EYES
Introduction
This form will provide valuable information to the NHS England Special School Eye Care Team to ensure they can:
- make the eye test and dispensing of glasses (if required) a positive experience for your child
- understand what is already known about the eye health and vision of your child
- receive other information about your child that will help them provide the best possible service.
We will be asking questions in the following categories:
- Your Child’s Details
- Your Details
- The Eye Test (Part 1)
- Eyecare History: Visits to the Optician / Visits to the Hospital
- Glasses
- Other Eye Information about your Child
- Other Health Information about your Child
- Eye Information about your Family
- The Eye Test (Part 2)
- 5 Key Questions
Completing the form

Not everything in this form will be relevant to your child but the more information you provide, the more we can tailor the service to your child’s specific needs.

Where answer options are provided, please click on  to indicate your choice.

Returning the form When completed, please return this to the school using the details on the Service Participation and Opt-Out form.

With much gratitude to SeeAbility for the content of this form
Consent for eye testing at school
Opt-out of eye testing at school
ABOUT MY CHILD’S EYES
Child’s Full Name
Today's date

DayMonthYear
Date
Address & Postcode
Date of Birth

DayMonthYear
Date
Phone Number
Please enter a valid phone number.Format: (00000000000).
Ethnicity
Name of Child’s GP
GP Practice Address
Your Details (Parent/Guardian)
Full Name
Address & Postcode
Phone Number
Please enter a valid phone number.Format: (00000000000).
Email
example@example.com
Relationship to Child
If any of the following are applicable, it would be useful for the Optometrist and Dispensing Optician to see these at the eye test:
- your child’s glasses
- the prescription from your child’s last eye test
- your child’s Education, Care and Health Plan or personal records
Would you like to attend your child’s eye test?
If Yes – please bring with you the three items mentioned above if available
If No – please arrange for the school to have these prior to the appointment if available
I am happy for the Optometrist to put drops in my child’s eyes.
These drops, also known as Cyclopentolate, help the Optometrist to see into the eye through the pupil. They may sting a little and vision may be blurry for a short time. Side effects are extremely rare.
Has your child had ever had an eye test at the Optician/Optometrist
If No/Don’t Know, go to next section
If yes, Name and address of current Optician/Optometrist?
Can the Eye Care Team contact the Optometrist to access your child's eye history?
Date of last check
Date of next check
Access to previous records can help the Eye Care Team provide a better service for your child
Eyecare History: Visits to the Hospital
Has your child ever been to the Eye Clinic in a Hospital?
If yes, what was the problem?
Name of the Hospital visited
Did your child have an operation
Date of last appointment
Date of next appointment
Hospital access to your child’s eye records

Access to previous records can help the Eye Care Team provide a better service for your child
Glasses
Has your child been prescribed glasses either by an Optician or from the Eye Clinic at a hospital?
If No/Don’t Know, go to next section
Has your child been given a patch for their glasses?
Is your child using their glasses now?
Does your child have any problems with their glasses?
If yes, please describe
Other Eye information about your Child
Is your child registered blind / severely sight impaired?
Is your child registered partially blind / severely sight impaired?
Do your child’s eyes always appear straight?
If one or both eyes appear to wander, which eye does this?
How often does this happen?
Do your child’s eyes appear to move excessively rapidly or uncontrollably?
Do you think your child has trouble controlling their eye movements?
If Yes, please give details:
Does your child tend to shut one eye?
Does your child appear very sensitive to bright lights?
Does your child complain of headaches?
Do you generally have concerns about your child’s eyes?
If Yes, please describe:
Does your child use a wheelchair?
Does your child have any health problems or disabilities?
If Yes, please describe them:
Does your child take any medication
If yes, please list them: (please take information about the medication to the eye test)
Does your child have any allergies?
If yes, please list them:
Please give details of any difficulties during the pregnancy or child’s birth: (eg. mother had infection, prematurity, low birth weight, need for special care, etc)
Eye information about your Family
Has anyone in your family had eye problems? For example, did anyone wear glasses as a child, had a squint (strabismus), a patch over an eye, or an eye condition?
If yes, please describe which family member in relation to yourself had the problem and what the problem was?Please describe who and what eye problems they
The Eye Test (Part 2)

When your child has their eye test, the Optometrist will need to look at their eyes and do some tests to check how well they can see. The information you give below will help the Optometrist to test your child’s eyes and communicate with them effectively.
Will your child be alright if the Optometrist comes close to them and shines a bright light in their eyes? This is done with an instrument called a Retinoscope.
Will your child be alright if the Optometrist was to cover their eyes one at a time?
Can your child understand better or worse?
Will your child be able to wear test frames on their face?
Can your child say or sign the names of letters on any Eye Test Chart?
Can your child say or sign the names of pictures on a chart (like house, fish, car)?
Can your child point to a letter or picture on a card that is the same letter or picture on a chart on the wall?
Is your child deaf or hard of hearing?
If yes, please give more details
Does your child find it hard to communicate?
Please indicate if your child uses any of the methods below to communicate and describe any other ways you might communicate with your child if appropriate?
Other ways:
5 Key Questions

These questions may not be applicable to your child but are used to help us identify if they might have problems with their vision that are due to their brain rather than their eyes (known as CVI – cerebral visual impairment).
1. Does your child have difficulty walking down stairs?
2. Does your child have difficulty seeing fast-moving objects?
3. Does your child have difficulty seeing something that is pointed out in the distance?
4. Does your child have difficulty locating an item of clothing in a pile of clothes?
5. Does your child find copying words or pictures time-consuming and difficult?
Finally, is there any other information about your child the Optometrist may need to know?
Thank you very much for detailing as much information as possible.

This will help the visiting NHS Eyecare Team to provide the best eye care possible for your child.

This information allow the NHS to measure and improve access, experiences and health outcomes for all patients from all communities.
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Special School Eye Care Service

ABOUT MY CHILD’S EYES

Introduction

ABOUT MY CHILD’S EYES

Your Details (Parent/Guardian)

Eyecare History: Visits to the Hospital

Glasses

Eye information about your Family

The Eye Test (Part 2)

5 Key Questions