Does your child report any headaches? If yes, when? Does your child report any double vision? If yes, when? Does your child report any blurred vision? If yes, when? Does your child report eyes hurting if tired? If yes, when? Does your child report car sickness? If yes, when?
Does your child report any of the following and if so when? (check all that apply)
Have you or anyone else noted the following (yes or no):Holding reading material close If yes, when? Closing or covering an eye when reading If yes, when? Eyes frequently red If yes, when? Excessive eye rubbing If yes, when? Excessive blinking If yes, when Getting "lost in the book" If yes, when? Tilting head when reading . If yes, when? . Inability to see distant objects clearly . If yes, when?. Bumping into objects If yes, when? Poor general coordination If yes, when? Bothered by light If yes, when? Extreme Fatigue If yes, when? Uses finger when reading If yes, when? Reverses or skips words If yes, when?
Please list previous vision/ eye exams, including doctor's name, date seen, reason for exam, and the results of that exam:
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 names and address)Pediatrician Teacher Tutor School counselor School nurse Learning or reading center Speech therapist Reading specialist Occupational therapist Physical therapist Special education teacher Other Other