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?

YesNo

If yes, what if your contact name?

Parents, please list any siblings your child has with their name, birthdate, age and grade.

0/100

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 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?

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:

AverageBetter than averageBelow 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:

GoodFairPoor

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 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

Children Questionnaire

Present Situation

School

Developmental History

General Health

Visual History

Contact Lens History