Children Questionnaire

Child's name:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home phone number

Area CodePhone Number

Child's date of birth

Child's School

Child's teachers name

Grade:

Referred by:

First NameLast Name:

Mother's name:

First NameLast Name

Occupation:

Date of birth:

Cell phone number

Area CodePhone Number

Work phone number

Area CodePhone Number

Email

example@example.com

Father's name:

First NameLast Name

Occupation:

Date of birth:

Cell phone number

Area CodePhone Number

Work phone number

Area CodePhone Number

Email:

example@example.com

Insurance Provider

Insurance ID #

Primary insured name:

First Name Last Name

Primary Insured date of birth:

Parents, may we add you on Facebook?

YesNo

If yes, what is your contact name?

First NameLast Name

Parents, please list any siblings your child has with their names, birthdates, ages, and grades.

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 our child report any headaches? if yes, when?

Does your child report any blurred vision?, if yes, when?

Does your child report of any double vision? If yes, when?

Does your child report of eyes hurting or tired? If yes, when?

Does your child report car sickness? if yes, when?

Have you or anyone else noted your child holding reading materials close? if yes, when?

Have you or anyone else noted your child closing or covering and eye when reading? If yes, when?

Have you or anyone else noted your child's eyes being frequently red? If yes, when?

Have you or anyone else noted your child having excessive eye blinking? If yes, when?

Have you or anyone else noted your child getting "lost in the book"? If yes, when?

Have you or anyone else noted your child tilting their head when reading? If yes, when?

Have you or anyone else noted that your child is unable to see distant objects clearly? If yes, when?

Have you or anyone else noted your child bumping into objects? If yes, when?

Have you or anyone else noted your child having poor general coordination? If yes, when?

Have you or anyone else noted your child being bothered by light? If yes, when?

Have you or anyone else noted your child being extremely fatigue? If yes, when?

Have you or anyone else noticed your child using a finger to read? if yes, when?

Have you or anyone else noted your child reversing or skipping 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 which seems paticularly 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 of 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?

At what age did your child walk alone?

At what age was your child when they spoke their first word?

Was your child and active baby?

YesNo

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?

When was your child's last eye 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 problems?

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 they interested?

When did they 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

Occupation therapist

Special education teacher

Other

Children Questionnaire

Present Situation

School

Developmental History

General Health

Visual History

Contact Lens History