Children’s Vision Therapy Questionnaire
Please complete this form and bring it with you to your initial Vision Therapy Evaluation appointment on
Patient’s Name: ______DOB_____/_____/______Grade ______
Appointment Date: _____/_____/______Time: ______A.M P.M.
General Information:
Were you referred to our office? Yes ___ No___
If yes, whom may we thank for this referral? ______
Child’s Family Information
Father/ Caretaker ______
Mother/ Caretaker ______
Sibling ______Age ______
Sibling ______Age ______
Sibling ______Age ______
Medical History
Pediatrician/Physician Name: ______
Clinic: ______
Current Medications: ______
______
Is your child generally healthy? Yes ___ No___
If no, please explain: ______
Are there any chronic problems like ear infections, asthma, hay fever, and allergies? Yes ___ No___
If yes, please list: ______
Has a neurological evaluation been performed? Yes ___ No___
By whom? ______
When? ______
Results/Recommendations: ______
Has a psychological evaluation been performed? Yes ___ No___
By whom? ______
When? ______
Results/Recommendations: ______
Has an occupational therapy evaluation been performed? Yes ___ No___
By whom? ______
When? ______
Results/Recommendations: ______
Is there any history of the following in your child’s family? Please mark (X) all that apply.
PatientFamily
Diabetes______
Glaucoma______
High Blood Pressure______
Learning Disability______
Amblyopia (lazy eye)______
Multiple Sclerosis______
Epilepsy or Seizures______
Brain Tumor______
Other: ______
Developmental History
Was the child delivered full term? Yes ___ No___
Did the mother experience any health problems during the pregnancy? Yes ___ No___
If yes, please explain: ______
Were there complications before, during, or immediately following the delivery? Yes ___ No___ Birth Weight: ______lbs. ______Oz.
Was there ever any concern over your child’s general growth or development? Yes ___ No___
If yes, why? ______
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? ______
Speech – What were your child’s first words? ______
Was early speech clear to others? Yes ___ No___
Is speech clear now?Yes ___ No___
Visual History
Has your child’s vision been previously evaluated? Yes ___ No___
Doctors Name: ______
Date of last Evaluation: ______
Reason for examination: ______
Results and recommendations: ______
Were glasses or contact lenses prescribed? ______
Visual History Continued
Does your child wear them constantly? Yes ___ No___
If no, when does the child wear them? ______
Present Situation
Why do you feel your child needs a Vision Therapy Evaluation?
Difficulty Reading ____Eye Turn/Strabismus ____
Headaches____Lazy Eye/ Ampblyopia____
Difficulty with Schoolwork ____Other Diagnosed Vision Problem____
How long has this problem/difficulty been observed? ______
Is there any evidence from 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?Yes No If yes, when?
Headaches______
Blurred vision/ in and out of focus______
Double vision______
Eyes hurt______
Eyes tired______
Words move around on the page______
Motion sickness/ carsickness______
Dizziness______
Please list any other complaints your child makes concerning his/her vision:
______
Have you or anyone else ever noticed the following?Yes No If yes, when?
Frequent eye rubbing______
Bothered by light______
Frequent blinking______
Closing or covering one eye______Difficulty seeing distant objects ______
Head close to paper when reading/ writing______
Avoids reading______
Prefers being read to______
Tilts head when reading______
Tilts head when writing______
Moves head when reading______Confuses letter or words ______
Reverses letter or words ______
Confuses left and right______
Skips, rereads, or omits words______
Loses place while reading______
Vocalizes when reading silently______
Reads slowly______
Present Situation Continued
Have you or anyone else ever noticed the following?Yes No If yes, when?
Uses finger as a marker______
Poor reading comprehension______
Comprehension decreases over time______
Writes neatly but slowly______
Does not support paper when writing______
Awkward or immature pencil grip______
Frequent erasures______
Tires easily______
Difficulty copying from chalkboard______
Difficulty recognizing same word______
Difficulty with memory______
Remembers better what hears than sees______
Responds better orally than by writing______
Seems to know material but tests poorly______
Dislikes/avoids near tasks______
Short attention span/loses interest______
Poor large motor coordination ______
Poor fine motor coordination______
Difficulty catching/hitting a ball______
School
Age at time of entrance to: Kindergarten: ______1st Grade: ______
Does your child like school?Yes ___ No___
Does your child seem to be under tension or extreme pressure when doing schoolwork? Yes ___ No___
Has your child had any special tutoring and/or remedial assistance? Yes ___ No___
IF yes, when? ______
From whom? ______
How long? ______
What school subjects are easy for your child? ______
What school subjects are difficult for your child? ______
Does your child like to read? Yes ___ No___
Does he/she do so voluntarily?Yes ___ No___
Please describe any specific school difficulties: ______
______
Overall, your child’s schoolwork is: Above Average ___Average ___Below Average ___
Do you feel your child is achieving his/her full potential?Yes ___ No___
Does the teacher feel your child is achieving his/her full potential?Yes ___ No___
Are there any behavior problems at school?Yes ___ No___
Please explain: ______
______
Are there any behavior problems at home?Yes ___ No___
Please explain: ______
______
School Continued
What is your child’s reaction to fatigue? ______
______
Does your child say and/or do things impulsively? Yes ___ No___
Is your child in constant motion? Yes ___ No___
Can your child sit still for long periods? Yes ___ No___
Family and Home
Please circle which adults your child lives with?
Mother Father Step-mother Step-father Grandmother/Father Foster Parents Adoptive parents other: ______
Has your child been through a traumatic family situation (divorce, parent/sibling loss, separation, severe parent/sibling illness)? Yes ___ No___
At what age: _____Please explain: ______
______
______
Does your child seem to have adjusted?Yes ___ No___
Is family like stable at this time?Yes ___ No___
How does our child get along with the following people?
Parents: ______
Siblings: ______
Schoolmates: ______
Playmates: ______
Did the child’s father or anyone in the father’s family have a learning problem? Yes ___ No___
If yes, who and what: ______
Did the child’s mother or anyone in the mother’s family have a learning problem? Yes ___ No___
If yes, who and what: ______
Did/do any of the child’s siblings have a learning problem? Yes ___ No___
If yes, who and what: ______
Please give a brief description of your child as a person: ______
______
______
Is there any other information you would like to share that you feel would be helpful/important in our treatment of your child? ______
______
Vision Therapy
Have you heard about Vision Therapy before?
How long have you been considering/researching Vision Therapy?
0-3 months ____4-6 months ____7-12 months ____
What questions/concerns do you have about Vision Therapy? ______
______
______
Have you had any other Vision Therapy Evaluations?Yes ___ No___
If yes, when? ______
Was therapy prescribed? ______
Thank you for your careful completion of this important information. The detailed information you supplied allows for a more comprehensive evaluation of your child, therefore, allowing us to better meet your child’s visual needs.
If at any time you have any questions or concerns please feel free to contact our office either by phone; (605) 271-5000 or email; .
Sincerely,
Center for Visual Learning
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