• Children Questionnaire

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

     

  • Present Situation

  • 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 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 _______ _______ ___________________

     

     

  • 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 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 __________________________________

     

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  • Should be Empty:
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