CHILDREN’S VISION QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of the medical record. Child’s Name First Last M F DOB MM slash DD slash YYYY Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Other Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneMobile PhoneEmail Name of school: Address of school: Street Address Address Line 2 City State / Province / Region Grade:How did you hear about us? RESPONSIBLE PERSON INFORMATIONFather/ Caretaker: First Last DOB: MM slash DD slash YYYY Father/Caretaker’s Home Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Occupation: Mobile Phone:Business Phone:Mother/ Caretaker: First Last DOB: MM slash DD slash YYYY Mother/Caretaker’s Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Occupation: Mobile PhoneBusiness PhonePlease list the names and ages of your immediate family: Name: Add RemoveAge: Add RemoveMEDICAL HISTORYPediatrician’s Name: First Last Date of Last Exam: MM slash DD slash YYYY Results and Recommendations from last Exam: Child’s current state of health: Medications currently using, including vitamins and supplements: Yes No For what conditions? What is the primary reason you are seeking a vision evaluation? How long has this problem/difficulty been observed? ALLERGIES: Add RemoveList Illnesses, Bad Falls, High Fevers, etc. Description Add RemoveAge Add RemoveSeverity Add RemoveComplications Add RemoveAre there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No please list: Has a neurological evaluation been performed? Yes No By whom? Results and recommendations: Has a psychological evaluation been performed? Yes No By whom? Results and recommendations: Has an occupational therapy evaluation been performed? Yes No By whom? Results and recommendations: Is there any history of the following? (please check)Diabetes Patient Family “Cross” or “Wall” eye Patient Family Chromosomal Imbalance Patient Family Glaucoma Patient Family Blindness Patient Family Brain Tumor Patient Family Cancer Patient Family Eye Infection Patient Family High Blood Pressure Patient Family Learning Disability Patient Family Amblyopia (lazy eye) Patient Family Multiple Sclerosis Patient Family Epilepsy or Seizures Patient Family Thyroid Condition Patient Family Cataracts Patient Family Eye Surgery Patient Family Eye Disease Patient Family Other Patient Family please explain: please explain: DEVELOPMENTAL HISTORYFull-term pregnancy? Yes No Did the mother experience any problems during the pregnancy? Yes No explain: Normal birth? Yes No explain: Were forceps used? Yes No Birth weight:Apgar scores at birth:After 10 mins.Any complications before, during or immediately following the delivery? Yes No explain: Were there any concerns regarding growth or development? Yes No explain: Did your child crawl (stomach on floor)? Yes No At what age?Did your child creep (on all fours)? Yes No At what age?At what age did your child walk?Was your child active? First words: At what age?Was early speech clear to others? Yes No Is speech clear now? Yes No VISUAL HISTORYHas your child’s vision been previously evaluated Yes No Doctor’s name: First Last Date of last evaluation: MM slash DD slash YYYY Reason for evaluation: Results and recommendations: Were glasses, contact lenses, or other optical devices prescribed or recommended? Yes No what? Are they used? Yes No Members of the family who have had visual attention and the reason:Name? Add RemoveAge? Add RemoveVisual Situation? Add RemoveIs there any evidence from the school, psychological, or other tests that indicates some visual malfunction may be present? Yes No What? PRESENT SITUATIONDoes your child report any of the following: Headaches Yes No When? Blurred vision Yes No When? Double vision Yes No When? Eyes tired Yes No When? Eyes hurt Yes No When? Motion sickness/car sickness Yes No when? Frequent sties Yes No When? Red or bloodshot eyes Yes No When? Watery eyes Yes No When? Bothered by light/light sensitivity Yes No When? Awkward or immature pencil grip Yes No When? Need to hold paper close when reading or writing Yes No When? Confuses right and left Yes No When? Confuses letters or words Yes No when? Skipping or omitting words Yes No When? Loss of place when reading Yes No when? Need to use finger to keep place Yes No When? Head moves when reading Yes No when? Silent vocalization/moving lips while reading Yes No When? Confusion of what is being seen or read Yes No When? Letters or words appear to move or float around when reading Yes No When? Difficulty aligning columns of numbers Yes No When? Poor reading comprehension Yes No When? Comprehension decrease over time Yes No When? Falling asleep when reading Yes No When? Writes or prints poorly Yes No When? Can respond better orally than in writing Yes No When? Tires easily Yes No When? Difficulty with short term memory Yes No When? Difficulty with long term memory Yes No When? Short attention span or loss of interest Yes No When? Difficulty attending to detail Yes No When? Poor/awkward general motor coordination Yes No When? Poor fine motor coordination Yes No When? Difficulty judging distances Yes No When? Difficulty driving Yes No When? Dislike/avoid sports Yes No When? Nausea associated with visual tasks Yes No When? Difficulty copying from chalkboard Yes No When? Tilts head during desk work or in general Yes No When? Squinting, covering or closing one eye Yes No When? Postural changes when doing desk work Yes No When? Need for very bright light or dim light when reading Yes No When? Loss of interest or short attention span for close work Yes No When? Difficulty sustaining reading or writing Yes No When? Visual fatigue at the end of the day Yes No When? Poor time management Yes No When? Inconsistent performance in work or sports Yes No When? Difficulty hitting or judging moving targets during sports Yes No When? List any other complaints you have concerning vision: Add RemoveDo you feel your child’s vision hinders his/her daily activities in any way? Yes No explain: Do you feel your child is achieving his/her potential? Yes No explain: SCHOOLHas your child had any special tutoring, therapy, and/or remedial assistance? Yes No when? Where and from whom? How long? Results? Does your child like to read? Yes No Voluntarily? Yes No Does your child read for pleasure? Yes No What kind of material? What is your child’s attitude toward school, his/her teachers, other children? Overall schoolwork is: Above Average Average Below Average Which Subjects Are:Above Average: Average: Below Average: Does your child need to spend a lot of time/effort to maintain this level of performance? Yes No How much time on average does your child spend each day on homework assignments?To what extent do you assist your child with homework? Does the teacher feel your child is achieving their potential? Yes No COMPUTERSDoes your child use a computer in their school or leisure time activities Yes No WORD PROCESSING PROGRAMMING DATA ENTRY INTERNET GAMES/LEISURE OTHER EXPLAIN How many hours do they spend in front of a computer screen each day? How do their eyes feel after working at the computer? Where is the top of the screen located? Above eye level At eye level Below eye level Do they wear glasses, contact lenses, or other optical devices for computer work? FAMILY AND HOMEPlease indicate which adult(s) he/she lives with? Mother Father Stepmother Stepfather Foster Parents Adoptive Parents Grandmother Grandfather Aunt Uncle Other Caretaker please specify Does anyone in the father’s family have a learning problem? Yes No Who? Does anyone in the mother’s family have a learning problem? Yes No Who? Please list all individuals who are able to pick up your child.Name: Add RemoveGive a brief description of your child as a person:Is there any other information you feel would be helpful/important in our treatment of your child?IF YOUR CHILD HAS A HISTORY OF EYE TURN/LAZY EYE/WANDERING EYE, PLEASE COMPLETE THE FOLLOWING SECTION, IF NOT PLEASE SKIP TO THE NEXT SECTION.AMBLYOPIA/STRABISMUS HISTORYWhat age was the eye turn first noticed or suspected? Did it begin turning Suddenly Gradually? Does the eye turn In out Up Down (Check all that apply)Is the eye turn getting Worse Better No Change? Is it always the same eye that turns? Yes No which eye? Right Left Is the eye turn always present? Yes No under what conditions is it present: Does the eye always turn in the same amount? Yes No explain: Any history in your family of an eye turn resulting from a disease or other condition? Yes No explain? Was there any related trauma or condition that preceded or accompanied the onset of the eye turn? Yes No explain: Do you notice the eye turns more when your child looks:Up close? Yes No In the distance? Yes No To the left? Yes No To the right? Yes No Up? Yes No Down? Yes No Does one pupil ever appear to be larger than the other? Yes No Do you ever notice one or both eyes shaking rapidly? Yes No If your child has a prescription, does the eye turn less when the prescription is worn? Yes No Have you been told your child has amblyopia (lazy eye)? Yes No Has there been any treatment using an eye patch? Yes No please describe when the patching was started, how much patching was done? (include age started, duration, eye patched and results)Has there been any surgical treatment? Yes No please describe the surgery? (include age when surgery was performed, # of operations, the eye operated on and results)Was the surgeon satisfied with the results of surgery? Yes No Explain: Were you satisfied with the results of surgery? Yes No Explain: Have the surgical results been maintained? Yes No Explain: Has there been any visual therapy? Yes No Doctors Name: First Last Please describe the type of visual therapy, including duration, age at which it was started and estimated results:Are you here for a second opinion regarding the surgery or other treatment? Yes No IF YOUR CHILD HAS A HISTORY OF HEAD INJURY, PLEASE COMPLETE THE FOLLOWING SECTION.BRAIN INJURY HISTORYDate of injury/accident: MM slash DD slash YYYY Type of injury/accident: Motor vehicle Fall Blow to head Industrial accident Medication-related Drug abuse Poison or toxic substance Carbon dioxide Drowning Cord around neck Stroke Aneurysm Hemorrhage Hypoxia Other What part of their head was affected: Forehead Right side Left side Back of head Top of head Face N/A Was the injury: Open Head (bleeding) Closed Head (non-bleeding) Did they lose consciousness? Yes No for how long: Were they in a coma? Yes No for how long: Symptoms immediately following the accident/injury: Double vision Headache Blurred Vision Dizziness Vomiting Pain in or around eyes Flashes of light Disorientation Loss of balance Neck pain/whiplash Loss of memory Restricted field of view Restricted motion When did you first see a doctor regarding their accident/injury? Name of Doctor: First Last Specialty: Where were they seen? Were they hospitalized? Yes No What were you and your family told? What did the initial treatments consist of? What prognosis/recommendations were they given? Were they given medications? Yes No Please listName medication Add RemoveFor what condition Add RemoveSUBSEQUENT/OTHER PROFESSIONAL CAREWhat types of professional care have you received or are you currently receiving? (check all that apply) Physician No Yes Name First Last Date MM slash DD slash YYYY Results: Physiatrist No Yes Name First Last Date MM slash DD slash YYYY Results: Neurologist Yes No Name First Last Date MM slash DD slash YYYY Results: Neurophysiologist Yes No Name First Last Date MM slash DD slash YYYY Results: Physical Therapist Yes No Name First Last Date MM slash DD slash YYYY Results: Speech/Language Therapist Yes No Name First Last Date MM slash DD slash YYYY Results: Psychologist/Psychiatrist Yes No Name First Last Date MM slash DD slash YYYY Results: Osteopathic Physician Yes No Name First Last Date MM slash DD slash YYYY Results: Other Yes No Name First Last Date MM slash DD slash YYYY Results: LIFESTYLEDo you feel your child’s vision interferes with activities of daily living? Yes No please explain (please include effects involving home, work, hobbies and personal relationships): What activities comprise the majority of their daily life since their accident/injury? What activities can they no longer engage in due to their visual or other difficulties? What other changes / limitations in their daily life do they attribute to their accident / injury? What do you hope a Visual Rehabilitation Program can do for your child? Privacy PolicyHealth Information Protection(Required) I have read and agree to the Privacy Policy Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA