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Pediatric VT History

Children's Vision Questionnaire-Extended Form

Patient's Name

Date

General Information

REFERRAL INFORMATION

Were you referred to our office? Yes No

If yes, whom may we thank for the referral?
Name	Phone

Address

CHILD INFORMATION

Child's Full Name

Gender Male Female

Date of Birth

Age:

Years

Months

Is your child afraid of doctors? No Yes
Has guidance been given in use of hand?	No Yes	Child's dominant hand	Right Left

SCHOOL INFORMATION

Name of School

Grade

Address of School

Teacher

Nurse

Principal

MEDICAL HISTORY

Pediatrician's Name	Phone Number
Address
Date of Last Exam	Reason for Visit
Results and Recommendations
Is your child generally healthy? Yes No	If no, please explain

Medications, Vitamins, and Supplements

   List all Medications and Reason For Medications Below

Name of Medication	Reason for Medication

Allergies

Specialist History

Has neurological evaluation been performed? Yes No	By Whom?
Neurological Results and Recommendations
Has psychological evaluation been performed?	By Whom?
Psychological Results and Recommendations
Has an occupational therapy evaluation been performed?	By Whom?
Occupational Therapy Results and Recommendations

Is There Any History of The Following?

Symptoms	Person Affected	Who/Comments
ADHD	Self Family
Amblyopia (Lazy Eye)	Self Family
Blindness	Self Family
Brain Tumor	Self Family
Chromosomal Imbalance	Self Family
Diabetes	Self Family
Dyslexia	Self Family
Epilepsy or Seizures	Self Family
Glaucoma	Self Family
High Blood Pressure	Self Family
Learning Disability	Self Family
Thyroid Condition	Self Family
Tubes in Ears	Self Family
Turned Eye	Self Family
Other	Self Family

If yes, did it result from a disease, trauma, or related condition?	Yes No
If yes, elaborate

Please describe any concussions, bad falls, high fevers, traumatic events, etc., and resulting complications.

Age	Event	Complications

NUTRITIONAL INFORMATION

Current Diet Excellent Good Fair Poor

Food Allergies and Sensitivities:

How active is your child? Minimally Moderately Extremely

DEVELOPMENTAL HISTORY

Pregnancy and Birth History

Did the mother have a full-term pregnancy? Yes No

Any health problems during the pregnancy? Yes No

If yes, please explain the health problems

Were there complications before, during, or immediately after delivery? Yes No

If yes, please describe complications.

Developmental Milestones

Age your child crawled (stomach on the floor)?

Age when your child creeped (stomach off floor)?

Age when child started to sit up unsupported?

Age when child walked?

Was your child active?

Speech

Age your child spoke his/her first words?	Age when first two word sentence was spoken?
Was early speech clear to others? Yes No	Is speech presently clear? Yes No
Please explain concerns about your child's speech
Please explain any developmental concerns

VISUAL HISTORY

Previous Treatments

Has your child's vision been previously evaluated? Yes No	If yes, date of last vision exam
Doctor's Name:	Practice phone number:
Practice Address:
Results and Recommendations (from the vision evaluation)
Were glasses, contact lenses, or other optical devices recommended? Yes No	If yes, what type: Single Vision Glasses Bifocal/No-line bifocals Contact lenses
When are they worn, or if not, why not?
If applicable, does the eye turn less when the prescription is worn? Not applicable Yes No Unsure	Has there been any treatment using an eye patch? Not applicable Yes No Unsure
If yes, please describe when the partching started, how patching was done, including age it started, the eye patched, the duration of treatment, and an estimate of the results:

Surgical History

Are you here for a second opinion regarding surgery or further treatment? Yes No
Has there been any surgical treatment? Yes No
If yes, please describe the surgery, including the age surgery was performed, the number of operations, the eye operated on, and an estimate of the cosmetic and function results.
Were you satisfied with the results of surgery? Yes No Unsure	Why?
Was the surgeon satisfied with the results of surgery? Yes No Unsure	Why?

Vision Therapy History

Has there been any vision therapy?	If yes, doctor's name:
Please describe the type of visual therapy, including its duration, the age it started, and the results.

CURRENT VISUAL SYMPTOMS

Please explain why do you feel your child needs a visual evaulation

How long has this visual problem/ difficulty been observed?

Parental Observation of Eye Turn (if applicable)

At what age did you first notice the eye turning?	How suddenly did the turn develop? Suddenly Gradually Unsure
Which direction(s) does the eye turn? Check all that apply.	Up Down Out In
Which eye turns? Right eye Left Eye Both eyes Unsure
Is the eye turn always present? Yes No Unsure	If no, when does it turn (i.e. when tired, sick, etc.)

Child Complaints

Does your child report any of the following?	Yes/No	If yes, how often? 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
Eyes tire when doing near work	Yes No Unsure	1 2 3 4
Words move around on the page	Yes No Unsure	1 2 3 4
Words run together when reading	Yes No Unsure	1 2 3 4
Falling asleep when reading	Yes NO Unsure	1 2 3 4
Motion sickness / Car sickness	Yes No Unsure	1 2 3 4
Dizziness or nausea associated with near work	Yes No Unsure	1 2 3 4
Eyes "hurt" or "tired"	Yes No Unsure	1 2 3 4
Headaches	Yes No Unsure	1 2 3 4
Vision worse at the end of the day	Yes No Unsure	1 2 3 4
Blurred vision	Yes No Unsure	1 2 3 4
Double vision	Yes No Unsure	1 2 3 4
Bothered by light	Yes No Unsure	1 2 3 4

REFRACTIVE STATUS AND FOCUSING SYMPTOMS

Have you or anyone else ever noticed the following symptoms?

Difficulty seeing distant objects	Yes No Unsure	1 2 3 4
Avoids reading or othe near tasks	Yes No Unsure	1 2 3 4
Blinking eyes	Yes No Unsure	1 2 3 4
Rubbing eyes	Yes No Unsure	1 2 3 4

Ocular Mobility Symptoms

Moves head when writing or reading	Yes No Unsure	1 2 3 4
Skips or omits words	Yes No Unsure	1 2 3 4
Uses finger as a marker	Yes No Unsure	1 2 3 4
Loses place while reading	Yes No Unsure	1 2 3 4
Reads slowly	Yes No Unsure	1 2 3 4

Eye Teaming (Binocularity Symptoms)

Closes or covers an eye	Yes No Unsure	1 2 3 4
Tilts head when reading or writing	Yes No Unsure	1 2 3 4
Inability to estimate distance accurately	Yes No Unsure	1 2 3 4

Eye-Hand Coordination Symptoms

Poor / awkward large motor coordination	Yes No Unsure	1 2 3 4
Poor/ awkward fine motor coordination	Yes No Unsure	1 2 3 4
Dislikes / avoids sports	Yes No Unsure	1 2 3 4
Writes or prints slowly	Yes No Unsure	1 2 3 4
Writes neatly, but slowly	Yes No Unsure	1 2 3 4
Does not support paper when writing	Yes No Unsure	1 2 3 4
Knows material but does poorly on tests	Yes No Unsure	1 2 3 4
Awkward or immature pencil grip	Yes No Unsure	1 2 3 4
Difficulty hitting / catch a ball	Yes No Unsure	1 2 3 4
Difficulty copying from the chalkboard	Yes No Unsure	1 2 3 4
More proficient in math than reading	Yes No Unsure	1 2 3 4
Difficulty catching / hitting a ball	Yes No Unsure	1 2 3 4
Misalign digits in a column of numbers	Yes No Unsure	1 2 3 4
Writing slants up or downhill	Yes No Unsure	1 2 3 4
Cannot stay on or between ruled lines	Yes No Unsure	1 2 3 4
Tendency to knock things over and bump into objects	Yes No Unsure	1 2 3 4

Visual Perception Symptoms

Confuses letters or words	Yes No Unsure	1 2 3 4
Reverses letters or words	Yes No Unsure	1 2 3 4
Difficulty with memory	Yes No Unsure	1 2 3 4
Remembers better what hears than sees	Yes No Unsure	1 2 3 4
Difficulty recognizing same word on a different page	Yes No Unsure	1 2 3 4
Confuses right and left	Yes No Unsure	1 2 3 4
Misplaces or loses papers, objects, belongings	Yes No Unsure

Other Symptoms

Says "I can't" before trying	Yes No Unsure	1 2 3 4
Takes an unreasonable amount of time to complete tasks	Yes No Unsure	1 2 3 4
Poor reading comprehension	Yes No Unsure	1 2 3 4
Reading comprehension decreases over time	Yes No Unsure	1 2 3 4
Vocalizes when reading silently	Yes No Unsure	1 2 3 4
Red eyes	Yes No Unsure	1 2 3 4
Frequently erase work	Yes No Unsure	1 2 3 4

DIGITAL DEVICE AND LEISURE TIME ACTIVITIES

How many hours per day does your child watch television?

How many hours per day does your child use a digital device?

What other activities occupy your child's leisure time? Please explain

Are there any activities your child would like to participate in, but does not? Please explain

ACADEMIC HISTORY

Age at entrance to:

Pre-school

Kindergarten

First Grade

Does your child like school? Yes No

Specifically describe and school difficulties. Please explain

Has your child changed schools often? Yes No

If yes, which schools and why? Please explain

Has a grade been repeated? Yes No

If yes, which grade(s) repeated and why? Please explain

Does your child seem to be under tension or extreme pressure when doing schoolwork? Yes No

Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No

If yes, what kind of assistance?

If yes, where did your child receive assistance and from whom?

If yes, how long did the assistance last?

If yes, what were the results of the assistance? Please explain

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

Overall academic performance is: Above average Average Below average

Subjects in School

Please list subjects in school where your child is performing at above average

Please list subjects in school where your child is performing at average

Please list subjects in school where your child is performing at below average

Does your child need to spend a lot of time / effort to maintain this level of performance? Yes No

Do you feel that your child is achieving up to potential? Yes No

How much time on average does your child spend each day on homework assignments? Please explain

To what extent do you assist your child with homework? Please explain

GENERAL BEHAVIOR

Are there any behavior problems at school? Yes No

If yes, what are the behavior problems at school? Please explain

Are there any behavior problems at home? Yes No

If yes, what are the behavior problems at home? Please explain

What causes these behavior problems at school / home? Please explain

What are your child's reaction to fatigue? sad irritable other

What are your child's reaction to tension? avoidance irritable other

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 indicate which adult(s) the child lives with (check all that apply):

stepmother father grandmother

stepfather mother grandfather

uncle foster parents

other caretaker

aunt &adoptive parents

Family Member Name	Age	Relationship
Mother:		Great Average Strained
Father:		Great Average Strained
Sibling:		Great Average Strained
Sibling:		Great Average Strained
Silbing:		Great Average Strained

Has your child been through a traumatic family situation such as divorce, parental loss, separation, severe parental illness?

If yes, what age was the child? Please explain

Does your child seem to have adjusted to the traumatic situation? Yes No

Was counseling and / or therapy involved with the traumatic situation? Yes No

If there was counseling and / or therapy, is it on-going? Yes No

Is the family life stable at this time? Yes No

If the family life is unstable at this time, please explain

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? Please explain

Adult VT History

Patient Information

Patient's Name:	Age:
Spouse/Significant Other Name:

Please answer the following for your Spouse or Significant Other:

DOB:	Occupation
Employer:	Bus. Phone:
Bus. Address:

Names and Birth Dates of Spouse and Dependents

Name	Birthdate

Referral Information

How did you hear about us? Flyer Workshop Our Website Facebook Twitter You Tube Linked In Magazine Article Newspaper Article TV Radio Family Reference Staff Reference School Nurse School Teacher School Counselor Speech-Language Pathologist Occupational Therapist Physical Therapist InfantSEE Program Postcard Exhibit Hall Booth Networking Meeting Presentation/Seminar Yellow Pages Yellow Pages Online Club/Organization Meeting Brochure Groupon/Living Social/Mother Lode Vision Screening Other Optometrist Pediatrician Doctor	If you were referred to our office, by whom?
Phone:
Address:	City:
State:	Zip Code:
UNUSED Please list any individuals who you would like a report sent (include name and address):

Visual History

Has there been a recent vision exam? yes no not sure	Date:	Name of Eye Doctor:
Results and Recommendations:
Are glasses or contacts worn? If so, how often? yes no not sure N/A	If no, why not?
What is the main reason for today's vision exam?
How long has this problem/difficulty been observed?	Amblyopia (lazy eye)? yes no not sure	When diagnosed?
List any treatment or therapy for this condition (past or present)?
Strabismus (eye turn)? yes no not sure	When diagnosed?
List any treatment or therapy for this condition (past or present)?
Do you enjoy reading?	What types of reading material do you enjoy?

Visual Symptom Survey

Please rank each of the following symptoms. 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always

Blur when looking at near	0 1 2 3 4	Misaligns digits/columns of numbers	0 1 2 3 4
Double vision	0 1 2 3 4	Reading comprehension declines over time	0 1 2 3 4
Headaches with near work	0 1 2 3 4	Poor/inconsistent in sports	0 1 2 3 4
Words run together when reading	0 1 2 3 4	Holds reading material too close	0 1 2 3 4
Burning, stinging, watery eyes when reading	0 1 2 3 4	Short attention span	0 1 2 3 4
Falls asleep when reading	0 1 2 3 4	Difficulty completing assignments on time	0 1 2 3 4
Vision worse at the end of the day	0 1 2 3 4	Says "I can't" before trying	0 1 2 3 4
Skips/repeats lines when reading	0 1 2 3 4	Avoids sports/games	0 1 2 3 4
Poor eye-hand coordination	0 1 2 3 4	Dizzy/Nausea with near work	0 1 2 3 4
Tilts head or closes one eye when reading	0 1 2 3 4	Does not judge distance accurately	0 1 2 3 4
Difficulty copying from far to near	0 1 2 3 4	Clumsy, knocks things over	0 1 2 3 4
Reversal of letters like b's, d's, p's and q's	0 1 2 3 4	Loses belongings/things	0 1 2 3 4
Avoids near work/reading	0 1 2 3 4	Car/motion sickness	0 1 2 3 4
Omits small words when reading	0 1 2 3 4	Forgetful/poor memory	0 1 2 3 4
Writes up/down hill	0 1 2 3 4	Sensitive to lighting (too light/too dark)	0 1 2 3 4

List any other vision related concerns:

Education/Employment Information

Current Status:

Part Time Student

Full Time Student

Retired

Part Time Employment

Full time Employment

Please answer the following if you are in an academic program:
School: Current Grade: preschool kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade college freshman college sophmore college junior college senior graduate student other Area of study:
Any special tutoring and/or remedial assistance? yes no not sure How long?
Describe the type and frequency of assistance:
Overall academic performance is: above average average below average not sure
Is a great deal of effort spent to maintain this level of performance? yes no not sure
Do you feel achievement is up to potential? yes no not sure
Does/Do the teacher(s) feel achievement is up to potential? yes no not sure
Other Comments about Academic Performance:

Medical History

Primary Care Doctor's Name: Address:
City: State: Zip Code:
Would you like a report sent to this doctor?

Medications:
(Including any vitamins & supplements)

For what condition(s)?

Med Allergies: NKDA
Reaction: Current state of health:

Injuries,Surgeries,Procedures

List any significant illnesses, head injury, surgical procedures, etc.:
                                                                                 Age              Severity                          Complications








Any chronic health problems like asthma, hay fever, allergies, etc.? yes no not sure

If yes, please explain:

Do you have problems now or previously in the following areas:

Cancer:	yes no not sure	If so, please explain:
Weight loss/gain:	yes no not sure	If so, please explain:
Skin:	yes no not sure	If so, please explain:
Allergies:	yes no not sure	If so, please explain:
Neurological:	yes no not sure	If so, please explain:
Ear/Nose/Throat:	yes no not sure	If so, please explain:
Psychological	yes no not sure	If so, please explain:
Endocrine/Hormone:	yes no not sure	If so, please explain:
Diabetes:	yes no not sure	If so, what type:	When was it diagnosed:
Heart or Vascular:	yes no not sure	If so, please explain:
Blood:	yes no not sure	If so, please explain:
Gastrointestinal:	yes no not sure	If so, please explain:
Kidney:	yes no not sure	If so, please explain:
Bladder:	yes no not sure	If so, please explain:
Muscle pain:	yes no not sure	If so, please explain:
Joint pain:	yes no not sure	If so, please explain:
Autoimmune disease:	yes no not sure	If so, please explain:
Other:	yes no not sure	If so, please explain:
Other:	yes no	If so, please explain:

Family History

Has anyone in the immediate family had or currently have any problems in the following areas:

Blindness:	yes no not sure	If so, who?
Diabetes:	yes no not sure	If so, who?
Macular Degeneration:	yes no not sure	If so, who?
Heart disease:	yes no not sure	If so, who?
Strabismus (eye turn):	yes no not sure	If so, who?
High blood pressure:	yes no not sure	If so, who?
Amblyopia (lazy eye):	yes no not sure	If so, who?
Kidney disease:	yes no not sure	If so, who?
Glaucoma:	yes no not sure	If so, who?
Thyroid disease:	yes no not sure	If so, who?
Retinal detachment:	yes no not sure	If so, who?
Cancer:	yes no not sure	If so, who?
Learning Disability:	yes no not sure	If so, who?
Rheumatoid arthritis:	yes no not sure	If so, who?

Other:

Special Testing

Has a neurological evaluation been performed? yes no If so, by whom?
Results and Recommendations:

Has a psychological evaluation been performed? yes no If so, by whom?
Results and Recommendations:

Has occupational therapy evaluation been performed? yes no If so, by whom?
Results and Recommendations:

Has a physical therapy evaluation been performed? yes no If so, by whom?
Results and Recommendations:

Has a speech/hearing evaluation been performed? yes no not sure If so, by whom?
Results and Recommendations:

Has educational testing been performed? yes no not sure If so, by whom?
Results and Recommendations:

Leisure Time Activities

Do you like to read? Yes No Do you read for pleasure?
What do you like to read?

List any hobbies or sports:               Performance in each?                    Do you wish to do better? If so, describe:








Other hobbies or sports:
Are there activities you would like to participate in, but don't?

Give a brief description of yourself as a person:

Is there any other information that you feel would be helpful/important for the doctor to know?