Child Vision Questionnaire Form Child Vision Questionnaire Please enable JavaScript in your browser to complete this form.1Information2Guardian Information3Medical History4Present Situation5Visual History6Lifestyle7Information ReleasePatient InformationAppointment Date & Time *DateTimeName of Authorized Representative (if applicable)Patient’s name on Care Card (Last, First) *Date of Birth *PHN (Care Card Number) *Gender *Address *City *Postal Code *Home Phone *Work PhoneLast Eye ExamFamily DoctorCurrent SchoolGradeTeacherPrincipalIs your child especially afraid of doctors?YESNOChild’s dominant hand:RIGHTLEFTHas guidance been given in use of hand?YESNOPlease list the names and birth dates of your family:RelationshipNameBirth DateRelationship 2Name 2Birth Date 2Relationship 3Name 3Birth Date 3Relationship 4Name 4Birth Date 4Relationship 5Name 5Birth Date 5Were you referred to our office? *YESNOIf yes, whom may we thank for this referral? *Referral’s Phone Number *Referral’s Address *Do you have extended health? *YESNOInsurance Company *Insured Member Name (Last, First) *Patient Relationship to Insured Member *Policy Number *Member ID *Do you have secondary coverage? *YESNOInsurance Company *Insured Member Name (Last, First) *Patient Relationship to Insured Member *Policy Number *Member ID *NextResponsible Person InformationPRIMARY CONTACTRelationship to patientPatient’s name on Care Card (Last, First) AddressCityPostal CodeHome PhoneWork PhoneBusiness AddressCityPostal CodeEmail AddressSECONDARY CONTACTRelationship to patientPatient’s name on Care Card (Last, First) AddressCityPostal CodeHome PhoneWork PhoneBusiness AddressCityPostal CodeEmail AddressPreviousNextMedical HistoryDate of last evaluationPhysician’s NameFor what problem/condition?Results and recommendationsChild’s current state of healthMedications currently using, including vitamins and supplementsFor what conditions?List illnesses, bad falls, high fevers, ear infections, head injuries, eye injuries, etc. (please include the age, severity and complications)Is your child generally healthy?YESNOIf no, please explain *Are there any chronic problems like ear infections, asthma, hay fever, allergies?YESNOIf yes, please list *Has a speech / language evaluation been performed?YESNOBy whom? *When? *Results and recommendations *Has an occupational therapy evaluation been performed?YESNOBy whom? *When? *Results and recommendations *Has a neurological evaluation been performed?YESNOBy whom? *When? *Results and recommendations *Has a psychological evaluation been performed?YESNOBy whom? *When? *Results and recommendations *Please indicate if you have had a history of any of the following conditions:DiabetesPatientFamilyPlease Specify *“Cross” or “Wall” eyePatientFamilyPlease Specify *Chromosal ImbalancePatientFamilyPlease Specify *GlaucomaPatientFamilyPlease Specify *Epilepsy or SeizuresPatientFamilyPlease Specify *High blood pressurePatientFamilyPlease Specify *Learning disabilityPatientFamilyPlease Specify *Amblyopia (Lazy eye)PatientFamilyPlease Specify *Multiple SclerosisPatientFamilyPlease Specify *OtherPatientFamilyPlease Specify *Current DietExcellentGoodFairPoorDoes your child:Like sweetsCrave sweetsIf yes, what types?Is your child active?YESNOModerately active?YESNOExtremely active?YESNOAre there periods of very high energy?YESNOVery low energy?YESNOPlease explainDEVELOPMENTAL HISTORYFull-term pregnancy?YESNODid the mother experience any health problems during the pregnancy?YESNOIf yes, explain *Normal birth?YESNOAny complications before, during or immediately following delivery?YESNOIf yes, explain *Birth weight:Apgar scores at birthAfter 10 minutesWere forceps used?YESNOWas there ever any reason for concern over your child’s general growth or development?YESNOIf yes, explain *Did your child crawl (stomach on floor)?YESNOAt what age?Did your child creep (on all fours)?YESNOAt what age? *If not, describe *At what age did your child walk?Was your child active?YESNOWhat was your childs first spoken words?At what age?Was early speech clear to others?YESNOIs speech clear now?YESNOPreviousNextPresent SituationWhy do you feel your child needs a visual evaluation?How long has this problem/difficulty been observed?Is there any evidence from the school, psychological, pediatric, occupational therapy, or speech/language tests that indicate some visual malfunction may be present?YESNOIf yes, please list *Does your child report any of the following:HeadachesYESNOIf yes, when & how often? *Blurred vision / focus goes in and outYESNOIf yes, when & how often? *Double visionYESNOIf yes, when & how often? *Eyes hurtYESNOIf yes, when & how often? *Eyes tiredYESNOIf yes, when & how often? *Words move around on the pageYESNOIf yes, when & how often? *Motion sickness / car sicknessYESNOIf yes, when & how often? *DizzinessYESNOIf yes, when & how often? *List any other complaints your child makes concerning his/her visionHave you or anyone else ever noticed the following:Eyes frequently reddenedYESNOIf yes, when & how often? *Frequent eye rubbingYESNOIf yes, when & how often? *Frequent stiesYESNOIf yes, when & how often? *FrowningYESNOIf yes, when & how often? *Bothered by lightYESNOIf yes, when & how often? *Frequent blinkingYESNOIf yes, when & how often? *Closing or covering one eyeYESNOIf yes, when & how often? *Difficulty seeing distant objectsYESNOIf yes, when & how often? *Head close to paper when reading or writingYESNOIf yes, when & how often? *Avoids readingYESNOIf yes, when & how often? *Prefers being read toYESNOIf yes, when & how often? *Tilts head when readingYESNOIf yes, when & how often? *Tilts head when writingYESNOIf yes, when & how often? *Moves head when readingYESNOIf yes, when & how often? *Confuses letter or words (circle one or both)YESNOIf yes, when & how often? *Reverses letters or words (circle one or both)YESNOIf yes, when & how often? *Confuses left and rightYESNOIf yes, when & how often? *Skipping, rereads and omits wordsYESNOIf yes, when & how often? *Loses place while readingYESNOIf yes, when & how often? *Vocalizes when reading silentlyYESNOIf yes, when & how often? *Reads slowlyYESNOIf yes, when & how often? *Uses finger as a markerYESNOIf yes, when & how often? *Poor reading comprehensionYESNOIf yes, when & how often? *Comprehension decreases over timeYESNOIf yes, when & how often? *Writes or prints poorlyYESNOIf yes, when & how often? *Writes neatly but slowlyYESNOIf yes, when & how often? *Does not support paper when writingYESNOIf yes, when & how often? *Awkward or immature pencil gripYESNOIf yes, when & how often? *Frequent erasuresYESNOIf yes, when & how often? *Tires easilyYESNOIf yes, when & how often? *Difficulty copying from the boardYESNOIf yes, when & how often? *Difficulty recognizing same word on different pageYESNOIf yes, when & how often? *Poor word attack skillsYESNOIf yes, when & how often? *Difficulty with memoryYESNOIf yes, when & how often? *Remembers better what hears than seesYESNOIf yes, when & how often? *Responds better orally than by writingYESNOIf yes, when & how often? *Seems to know material, but does poorly on testsYESNOIf yes, when & how often? *Dislikes / avoids near tasksYESNOIf yes, when & how often? *Short attention span / loses interestYESNOIf yes, when & how often? *Poor large motor coordinationYESNOIf yes, when & how often? *Poor fine motor coordinationYESNOIf yes, when & how often? *Difficulty with scissors / small hand toolsYESNOIf yes, when & how often? *Dislikes / avoids sportsYESNOIf yes, when & how often? *Difficulty catching / hitting a ballYESNOIf yes, when & how often? *PreviousNextVisual HistoryHas your child’s vision been previously evaluated? *YESNOIf so, Doctor’s Name *Date of last evaluation *Reason for examination *Results and recommendations *Were glasses, contact lenses, or other optical devices recommended? *YESNOIf yes, please list *Are they used? *YESNOIf yes, when? *If not used, why not? *Was Vision Therapy prescribed? *YESNOWas Vision Therapy done? *YESNOIf yes, for how long? *Members of the family who have required visual attention and reason:NameAgeVisual situationName 2Age 2Visual situation 2Name 3Age 3Visual situation 3Name 4Age 4Visual situation 4Name 5Age 5Visual situation 5PreviousNextLifestyleDoes child watch TV?YesNoHow much? *How often? *Viewing distance? *Does your child spend time using computer/video games?YESNOIf yes, how much? *How often? *Viewing distance? *What other activities occupy your child’s leisure time?Are there any activities your child would like to participate in, but doesn’t? Please explain.Age at time of entrance to:Pre-schoolKindergartenFirst GradeDoes your child like school?YESNOSpecifically describe any school difficultiesHas your child changed schools often?YESNOIf yes, when? *Has a grade been repeated?YESNOIf yes, which and why? *Does your child seem to be under tension or extreme pressure when doing schoolwork?YESNODoes your child avoid homework?YESNODoes your child take too long to do homework?YESNOHas your child had any special tutoring, therapy, and/or remedial assistance?YESNOIf yes, please state when, where and from whom, how long and the results *What school subjects are difficult for your child?What school subjects are difficult for your child?Does your child like to read?YESNOVoluntarily?YESNODoes your child read for pleasure?YESNOWhat?Does your child like to be read to?YESNOWhat is your child’s attitude toward reading, school, his/her teachers, other youngsters?Does your child have an I.E.P.?YESNOOverall schoolwork is:Above averageAverageBelow averageDo you feel your child is achieving up to potential?YESNODoes the teacher feel your child is achieving up to potential?YESNOAre there any behaviour problems at school?YESNOIf yes, please explain *Are there any behaviour problems at home?YESNOIf yes, please explain *What causes these problems?Your child’s reaction to fatigue?SagIrritabilityOtherYour child’s reaction to fatigue? (Other) *Your child’s reaction to tension?AvoidanceNail-bitingThumb-suckingOtherYour child’s reaction to tension? (Other) *Does your child say and/or do things impulsively?YESNOIs your child in constant motion?YESNOCan your child sit still for long periods?YESNOPlease indicate which adult(s) he/she lives with? (select all that apply)MotherFatherStepmotherStepfatherFoster ParentsAdoptive ParentsGrandmotherGrandfatherAunt UncleOther Caretaker (please specify)Please indicate which adult(s) he/she lives with? (Other) *Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)?YESNOIf yes, at what age? *Does your child seem to have adjusted?YESNOWas counseling/therapy undertaken?YESNOIf yes, is it on-going? *YESNOIs family life stable at this time?YESNOIf no, please explain *How does your child get along with:Parents/other caretakers?Siblings?Classmates in school?Playmates at home?Does the father or anyone in the father’s side of the family have a learning problem?YESNOIf yes, who? *Does the mother or anyone in the mother’s side of the family have a learning problem?YESNOIf yes, who? *Do any, or did any, of the other children in the family have learning problems?YESNOIf yes, who? *To what extent? *Give a brief description of your child as a personIs there any other information you feel would be helpful/important in our treatment of your child?PreviousNextRelease of InformationIt is often beneficial to us to discuss examination results and to exchange information with other professionals involved in your care. Please sign below to authorize the release of information. I agree to permit information from, or copies of, my examination records to be exchanged with other health care providers upon their written request or upon the recommendation of EYELAB – DOCTORS OF OPTOMETRY when it is necessary for the treatment of my visual condition. This authorization shall be considered valid for the duration of treatment.Type Full Name of Parent or Guardian *Relationship to Patient *Date *I hereby give my permission to EYELAB to treat (child’s name) *Date * Cancellation Policy Cancellation of appointment requires a minimum of 24 hour notice. A $50 cancellation or no-show fee will be required if appointment is cancelled within the 24 hour window. PreviousSubmit