Children Questionnaire

Child's name:

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home phone number

Area Code Phone Number

Child's date of birth

School and teacher's name:

Grade:

Referred by:

Mother's name:

Occupation:

Date of birth:

Cell phone number

Area Code Phone Number

Work phone number

Area Code Phone Number

Email:

Father's name:

Occupation

Date of birth:

Cell phone number

Area Code Phone Number

Work phone number

Area Code Phone Number

Email:

Insurance Provider

Insurance ID #

Primary Insured Name:

Primary Insured date of birth:

Parents, may we add you on Facebook?

Yes No

If yes, what if your contact name?

Brothers and Sisters	Birthdate	Age	Grade
_________________	_______	_____	______
_________________	_______	_____	______
_________________	_______	_____	______

In what ways does your child seem to have visual and/or school difficulties?

How long has the difficulty been noted?

What kind of complaints does your child have about his/her vision?

Does your child report any of the following and if so when? (check all that apply)

Headaches and when__________________________________ Blurred vision and when ________________________________ Double vision and when _______________________________ Eye hurts if tired and when _____________________________ Carsickness and when __________________________________

Have you or anyone else noted the following:

	Yes	No	When
Holding reading material close	_______	_______	___________________
Closing or covering an eye when reading	_______	_______	___________________
Eyes frequently red	_______	_______	___________________
Excessive eye rubbing	_______	_______	___________________
Excessive blinking	_______	_______	___________________
Getting "lost in a book"	_______	_______	___________________
Tilting head when reading	_______	_______	___________________
Inability to see distant objects clearly	_______	_______	___________________
Bumping into objects	_______	_______	___________________
Poor general coordination	_______	_______	___________________
Bothered by light	_______	_______	___________________
Extreme fatigue	_______	_______	___________________
Uses finger when reading	_______	_______	___________________
Reverses or skips words	_______	_______	___________________

Age at time of entrance to nursery school:

Kindergarten:

First grade:

Does your child like school? If no, why not?

Has a grade been repeated?

If so, which grade(s):

Have there been any school difficulties? If so, please explain:

Is school work:

Average Better than average Below average

Is there any subject which seems particularly easy for your child?

Is there any subject with seems particularly difficult for your child?

Has any special testing or remedial work been done? If so, by whom and when?

Has there been any specific diagnosis?

Term or pregnancy

Normal birth or were there any complications before, during or immediately following delivery?

Did your child crawl? At what age?

At what age did your child sit alone?

Walk alone?

Speech: Age when first word was spoken?

Was your child an active baby?

When fatigued, what does your child do? (become irritable, excited?)

Please list past illnesses including any history of high fever or significant injuries and the age at which they occurred:

Health at the present time is:

Good Fair Poor

Is your child under any medication? If so, what?

Does your child have any allergies?

Name and address of pediatrician:

Is there any family history of diabetes, high blood pressure or other serious health conditions?

Have your child's eyes ever been crossed or turned out? If yes, when?

Have you ever been told that your child has a "lazy" eye?

Please list previous vision/eye exams, including doctor's name, date seen, reason for exam, and the results of that exam:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Are there other members of the family who have had vision or eye problems? If yes, what kind of problem(s)?

Please give a brief description of your child's personality:

Is there anything else you want us to know that you don't want to say in front of your child?

Does your child wear contact lenses?

Soft or RGP?

If not, are you interested?

When did you start wearing contact lenses?

What type and brand of contact lenses:

How many hours per day and per week?

We would like to share our findings with other professionals who participate in the care and education of your child. Please check any of the following to whom you would like us to send a report. (Please include full name and address)

_____	Pediatrican	__________________________________
_____	Teacher	__________________________________
_____	Tutor	__________________________________
_____	School counselor	__________________________________
_____	School nurse	__________________________________
_____	Learning or reading center	__________________________________
_____	Speech therapist	__________________________________
_____	Reading specialist	__________________________________
_____	Occupational therapist	__________________________________
_____	Physical therapist	________________________________
_____	Special Education teacher	__________________________________
_____	Other	__________________________________

Children Questionnaire

Present Situation

School

Developmental History

General Health

Visual History

Contact Lens History