Children’s Vision Questionnaire WELCOME TO OUR CLINIC! INSIGHT OPTOMETRY CHILDRENS VISION QUESTIONNAIRE To better assist you, we would ask that you kindly fill out this form. "*" indicates required fields Patient’s Name:* First Last Caretakers Name:Relationship to Patient:Occupation:Caretakers Name:Relationship to Patient:Occupation:Caretaker's Phone Number:Caretaker's Email Address: GENERAL INFORMATIONWere you referred to our office? Yes No By whom?Patients Age: YearsPatients Age: MonthsChild’s dominant hand: Right Left MEDICAL HISTORYMedications currently using, including vitamins and supplements:For what condition(s)?Any Previous Health Concerns?Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No If yes, 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:Does your child report any of the following?Eye Turn/ “Cross” eye: Yes No If so, who?Amblyopia (Lazy eye): Yes No If so, who?Learning Disability: Yes No If so, who?PRESENT 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, or other tests that indicates some visual malfunction may be present? Yes No If yes, what?Does your child report any of the following?Headaches Yes No If yes, when?Blurred vision / focus goes in and out Yes No If yes, when?Double vision Yes No If yes, when?Eyes hurt Yes No If yes, when?Eyes tired Yes No If yes, when?Words move around on the page Yes No If yes, when?Motion sickness / car sickness Yes No If yes, when?Dizziness Yes No If yes, when?List any other complaints your child makes concerning his/her vision:HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING:Eyes frequently reddened Yes No If yes, when?Frequent eye rubbing Yes No If yes, when?Bothered by light Yes No If yes, when?Frequent blinking Yes No If yes, when?Closing or covering one eye Yes No If yes, when?Head close to paper when reading or writing Yes No If yes, when?Avoids reading Yes No If yes, when?Prefers being read to Yes No If yes, when?Tilts head when reading Yes No If yes, when?Tilts head when writing Yes No If yes, when?Moves head when reading Yes No If yes, when?Confuses letter or words Yes No If yes, when?Reverses letter or words Yes No If yes, when?Confuses right and left Yes No If yes, when?Skips, rereads or omits words Yes No If yes, when?Loses place while reading Yes No If yes, when?Vocalizes when reading silently Yes No If yes, when?Reads slowly Yes No If yes, when?Uses finger as a marker Yes No If yes, when?Poor reading comprehension Yes No If yes, when?Comprehension decreases over time Yes No If yes, when?Writes or prints poorly Yes No If yes, when?Writes neatly but slowly Yes No If yes, when?Does not support paper when writing Yes No If yes, when?Awkward or immature pencil grip Yes No If yes, when?Tires easily Yes No If yes, when?Difficulty copying from chalkboard Yes No If yes, when?Difficulty recognizing same word on different page Yes No If yes, when?Difficulty with memory Yes No If yes, when?Remembers better what hears than sees Yes No If yes, when?Responds better orally than by writing Yes No If yes, when?Seems to know material, but does poorly on tests Yes No If yes, when?Short attention span / loses interest Yes No If yes, when?Poor large motor coordination Yes No If yes, when?Poor fine motor coordination Yes No If yes, when?Difficulty with scissors / small hand tools Yes No If yes, when?Dislikes / avoids sports Yes No If yes, when?Difficulty catching / hitting a ball Yes No If yes, when?SCHOOLDoes your child like school? Yes No Specifically describe any school difficulties:Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No If yes, when?Where and from whom?How long?Results:Does your child like to read? Yes No Voluntarily? Yes No Overall school work is Above Average Average Below Average WHICH SUBJECTS ARE:Above average:Below average:Does your child need to spend a lot of time/effort to maintain this level of performance? Yes No Do you feel your child is achieving up to potential? Yes No Does the teacher feel your child is achieving up to potential? Yes No GENERAL BEHAVIOURAre there any behaviour concerns at school? Yes No If yes, what?Are there any behaviour concerns at home? Yes No If yes, what?What triggers these actions?Does your child react with any of the following behaviours when they are angry, frustrated, upset or dysregulated? If yes, please check off any/all that apply. Hitting Kicking Head butting (objects or people) Biting Spitting Punching Pinching Scratching Licking Does your child stim to help regulation? Yes No If yes, how?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?IS THERE ANYTHING YOUR CHILD LIKES/ DISLIKES? Δ
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