Child Vision Questionnaire Form

Child Vision Questionnaire

1Information

2Guardian Information

3Medical History

4Present Situation

5Visual History

6Lifestyle

7Information Release

Patient Information

Appointment Date & Time *

Date

Time

Name 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 Phone

Last Eye Exam

Family Doctor

Current School

Grade

Teacher

Principal

Is your child especially afraid of doctors?

Child’s dominant hand:

RIGHT
LEFT

Has guidance been given in use of hand?

Please list the names and birth dates of your family:

Relationship

Name

Birth Date

Relationship 2

Name 2

Birth Date 2

Relationship 3

Name 3

Birth Date 3

Relationship 4

Name 4

Birth Date 4

Relationship 5

Name 5

Birth Date 5

Were you referred to our office? *

If yes, whom may we thank for this referral? *

Referral’s Phone Number *

Referral’s Address *

Do you have extended health? *

Insurance Company *

Insured Member Name (Last, First) *

Patient Relationship to Insured Member *

Policy Number *

Member ID *

Do you have secondary coverage? *

Insurance Company *

Insured Member Name (Last, First) *

Patient Relationship to Insured Member *

Policy Number *

Member ID *

Responsible Person Information

PRIMARY CONTACT

Relationship to patient

Patient’s name on Care Card (Last, First)

Address

City

Postal Code

Home Phone

Work Phone

Business Address

City

Postal Code

Email Address

SECONDARY CONTACT

Relationship to patient

Patient’s name on Care Card (Last, First)

Address

City

Postal Code

Home Phone

Work Phone

Business Address

City

Postal Code

Email Address

Medical History

Date of last evaluation

Physician’s Name

For what problem/condition?

Results and recommendations

Child’s current state of health

Medications currently using, including vitamins and supplements

For 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?

If no, please explain *

Are there any chronic problems like ear infections, asthma, hay fever, allergies?

If yes, please list *

Has a speech / language evaluation been performed?

By whom? *

When? *

Results and recommendations *

Has an occupational therapy evaluation been performed?

By whom? *

When? *

Results and recommendations *

Has a neurological evaluation been performed?

By whom? *

When? *

Results and recommendations *

Has a psychological evaluation been performed?

By whom? *

When? *

Results and recommendations *

Please indicate if you have had a history of any of the following conditions:

Diabetes

Patient
Family

Please Specify *

“Cross” or “Wall” eye

Patient
Family

Please Specify *

Chromosal Imbalance

Patient
Family

Please Specify *

Glaucoma

Patient
Family

Please Specify *

Epilepsy or Seizures

Patient
Family

Please Specify *

High blood pressure

Patient
Family

Please Specify *

Learning disability

Patient
Family

Please Specify *

Amblyopia (Lazy eye)

Patient
Family

Please Specify *

Multiple Sclerosis

Patient
Family

Please Specify *

Other

Patient
Family

Please Specify *

Current Diet

Excellent
Good
Fair
Poor

Does your child:

Like sweets
Crave sweets

If yes, what types?

Is your child active?

Moderately active?

Extremely active?

Are there periods of very high energy?

Very low energy?

Please explain

DEVELOPMENTAL HISTORY

Full-term pregnancy?

Did the mother experience any health problems during the pregnancy?

If yes, explain *

Normal birth?

Any complications before, during or immediately following delivery?

If yes, explain *

Birth weight:

Apgar scores at birth

After 10 minutes

Were forceps used?

Was there ever any reason for concern over your child’s general growth or development?

If yes, explain *

Did your child crawl (stomach on floor)?

At what age?

Did your child creep (on all fours)?

At what age? *

If not, describe *

At what age did your child walk?

Was your child active?

What was your childs first spoken words?

At what age?

Was early speech clear to others?

Is speech clear now?

Present Situation

Why 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?

If yes, please list *

Does your child report any of the following:

Headaches

If yes, when & how often? *

Blurred vision / focus goes in and out

If yes, when & how often? *

Double vision

If yes, when & how often? *

Eyes hurt

If yes, when & how often? *

Eyes tired

If yes, when & how often? *

Words move around on the page

If yes, when & how often? *

Motion sickness / car sickness

If yes, when & how often? *

Dizziness

If yes, when & how often? *

List any other complaints your child makes concerning his/her vision

Have you or anyone else ever noticed the following:

Eyes frequently reddened

If yes, when & how often? *

Frequent eye rubbing

If yes, when & how often? *

Frequent sties

If yes, when & how often? *

Frowning

If yes, when & how often? *

Bothered by light

If yes, when & how often? *

Frequent blinking

If yes, when & how often? *

Closing or covering one eye

If yes, when & how often? *

Difficulty seeing distant objects

If yes, when & how often? *

Head close to paper when reading or writing

If yes, when & how often? *

Avoids reading

If yes, when & how often? *

Prefers being read to

If yes, when & how often? *

Tilts head when reading

If yes, when & how often? *

Tilts head when writing

If yes, when & how often? *

Moves head when reading

If yes, when & how often? *

Confuses letter or words (circle one or both)

If yes, when & how often? *

Reverses letters or words (circle one or both)

If yes, when & how often? *

Confuses left and right

If yes, when & how often? *

Skipping, rereads and omits words

If yes, when & how often? *

Loses place while reading

If yes, when & how often? *

Vocalizes when reading silently

If yes, when & how often? *

Reads slowly

If yes, when & how often? *

Uses finger as a marker

If yes, when & how often? *

Poor reading comprehension

If yes, when & how often? *

Comprehension decreases over time

If yes, when & how often? *

Writes or prints poorly

If yes, when & how often? *

Writes neatly but slowly

If yes, when & how often? *

Does not support paper when writing

If yes, when & how often? *

Awkward or immature pencil grip

If yes, when & how often? *

Frequent erasures

If yes, when & how often? *

Tires easily

If yes, when & how often? *

Difficulty copying from the board

If yes, when & how often? *

Difficulty recognizing same word on different page

If yes, when & how often? *

Poor word attack skills

If yes, when & how often? *

Difficulty with memory

If yes, when & how often? *

Remembers better what hears than sees

If yes, when & how often? *

Responds better orally than by writing

If yes, when & how often? *

Seems to know material, but does poorly on tests

If yes, when & how often? *

Dislikes / avoids near tasks

If yes, when & how often? *

Short attention span / loses interest

If yes, when & how often? *

Poor large motor coordination

If yes, when & how often? *

Poor fine motor coordination

If yes, when & how often? *

Difficulty with scissors / small hand tools

If yes, when & how often? *

Dislikes / avoids sports

If yes, when & how often? *

Difficulty catching / hitting a ball

If yes, when & how often? *

Visual History

Has your child’s vision been previously evaluated? *

If so, Doctor’s Name *

Date of last evaluation *

Reason for examination *

Results and recommendations *

Were glasses, contact lenses, or other optical devices recommended? *

If yes, please list *

Are they used? *

If yes, when? *

If not used, why not? *

Was Vision Therapy prescribed? *

Was Vision Therapy done? *

If yes, for how long? *

Members of the family who have required visual attention and reason:

Name

Age

Visual situation

Name 2

Age 2

Visual situation 2

Name 3

Age 3

Visual situation 3

Name 4

Age 4

Visual situation 4

Name 5

Age 5

Visual situation 5

Lifestyle

Does child watch TV?

How much? *

How often? *

Viewing distance? *

Does your child spend time using computer/video games?

If 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-school

Kindergarten

First Grade

Does your child like school?

Specifically describe any school difficulties

Has your child changed schools often?

If yes, when? *

Has a grade been repeated?

If yes, which and why? *

Does your child seem to be under tension or extreme pressure when doing schoolwork?

Does your child avoid homework?

Does your child take too long to do homework?

Has your child had any special tutoring, therapy, and/or remedial assistance?

If yes, please state when, where and from whom, how long and the results *

What school subjects are difficult for your child?

Does your child like to read?

Voluntarily?

Does your child read for pleasure?

What?

Does your child like to be read to?

What is your child’s attitude toward reading, school, his/her teachers, other youngsters?

Does your child have an I.E.P.?

Overall schoolwork is:

Above average
Average
Below average

Do you feel your child is achieving up to potential?

Does the teacher feel your child is achieving up to potential?

Are there any behaviour problems at school?

If yes, please explain *

Are there any behaviour problems at home?

If yes, please explain *

What causes these problems?

Your child’s reaction to fatigue?

Sag
Irritability
Other

Your child’s reaction to fatigue? (Other) *

Your child’s reaction to tension?

Avoidance
Nail-biting
Thumb-sucking
Other

Your child’s reaction to tension? (Other) *

Does your child say and/or do things impulsively?

Is your child in constant motion?

Can your child sit still for long periods?

Please indicate which adult(s) he/she lives with? (select all that apply)

Mother
Father
Stepmother
Stepfather
Foster Parents
Adoptive Parents
Grandmother
Grandfather
Aunt
Uncle
Other 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)?

If yes, at what age? *

Does your child seem to have adjusted?

Was counseling/therapy undertaken?

If yes, is it on-going? *

Is family life stable at this time?

If 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?

If yes, who? *

Does the mother or anyone in the mother’s side of the family have a learning problem?

If yes, who? *

Do any, or did any, of the other children in the family have learning problems?

If yes, who? *

To what extent? *

Give 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?

Release of Information

It 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.