• Children Questionnaire

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  • Present Situation

  • 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?      

  • School

  • Developmental History

  • General Health

  • Visual History

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

       

       
       
       

  • Contact Lens History

  • 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      

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