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Pediatric VT History

Children's Vision Questionnaire-Extended Form

Type Of Visit:

Type of Visit

Date

CHILD INFORMATION

Child's Full Name

Gender Male Female

Date of Birth

Age:

Years

Months

Has guidance been given in use of hand?

No Yes

Child's dominant hand

Right Left

General Information

REFERRAL INFORMATION

How did you hear about us? Yes No

If you were refered, whom may we thank?
Name	Phone

Address

VISUAL HISTORY

Previous Treatments

For initial vists, please explain why do you feel your child needs a visual evaluation

How long has this visual problem/ difficulty been observed?

Are you here for a second opinion regarding surgery or further treatment?

Yes No Other

If therapy is recommended, what are your goals?

Child Complaints

REFRACTIVE STATUS AND FOCUSING SYMPTOMS

Have you or anyone else ever noticed the following symptoms?

Does your child report any of the following?	Yes/No	If yes, how often? 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
Blurred distance vision	Yes No Unsure	1 2 3 4
Blurred near vision	Yes No Unsure	1 2 3 4
Vision worse at the end of the day	Yes No Unsure	1 2 3 4
Headaches	Yes No Unsure	1 2 3 4
Eyes "hurt" or "tired" after near work	Yes No Unsure	1 2 3 4
Avoids reading or other near tasks	Yes No Unsure	1 2 3 4
Lag in focus	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 repeats lines when reading	Yes No Unsure	1 2 3 4
Loses place while reading	Yes No Unsure	1 2 3 4
Uses finger as a marker	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
Reads slowly	Yes No Unsure	1 2 3 4
Double vision	Yes No Unsure	1 2 3 4
Words move around on the page	Yes No Unsure	1 2 3 4
Words run togehter when reading	Yes No Unsure	1 2 3 4
Car or motion sickness	Yes No Unsure	1 2 3 4
Poor reading comprehension	Yes No Unsure	1 2 3 4
Does not judge 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
Clumsy, knocks things over	Yes No Unsure	1 2 3 4
Poor / inconsistent in sports	Yes No Unsure	1 2 3 4
Knows material but does poorly on tests	Yes No Unsure	1 2 3 4
Writes poorly or slowly	Yes No Unsure	1 2 3 4
Difficulty copying from the chalkboard	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 our between ruled lines	Yes No Unsure	1 2 3 4

Visual Perception Symptoms

Confuses right and left	Yes No Unsure	1 2 3 4
Confuses letters or words	Yes No Unsure	1 2 3 4
Reverses letters or words	Yes No Unsure	1 2 3 4
Reverses letters or words	Yes No Unsure	1 2 3 4
Forgetful / poor memory	Yes No Unsure	1 2 3 4
Trouble following directions	Yes No Unsure	1 2 3 4
Difficulty recognizing same word on a different page	Yes No Unsure	1 2 3 4
Misplaces belongings	Yes No Unsure	1 2 3 4
Can't spell known sight words	Yes No Unsure	1 2 3 4
Difficulty attending to details	Yes No Unsure	1 2 3 4
Vocalizes when reading silently	Yes No Unsure	1 2 3 4

Other Symptoms

Says "I can't" before trying	Yes No Unsure	1 2 3 4
Difficulty completing tasks on time	Yes No Unsure	1 2 3 4
Bothered by light	Yes No Unsure	1 2 3 4
Dizziness	Yes No Unsure	1 2 3 4

List any other complaints your child continues to make concerning his / her vision

Do you feel your child's vision continues to hinder his / her daily activities? if yes, how?

EFFECTIVENESS OF VISION THERAPY (for progress visits only.)

Please describe any new or unresolved concerns since starting therapy.

How has vision therapy improved your child's life?

May we share your success story with others (first names only)?

Yes No Other

May we share your contact information with prospective therapy students for referral purposes?

Yes No Other

Is There Any History of The Following?

Symptoms	Person Affected	Who/Comments
Amblyopia (Lazy Eye)	Self Family
Blindness	Self Family
Cataract	Self Family
Diabetic Eye Disease	Self Family
Eye Injury	Self Family
Glaucoma	Self Family
Macular Disease	Self Family
Retinal Disease	Self Family
Strabismus	Self Family
Other

Parental Observation of Eye Turn (if applicable)

Which eye turns?

Right eye Left Eye Both eyes Unsure Other

Which direction(s) does the eye turn?

In Out Up Down Other

At what age did the turn start?

Did the turn begin gradually or suddenly?

Suddenly Gradually Unsure Other

Is the turn getting better, worse, or no change?

Staying the same Getting worse Getting better Other

Under what circumstances does it turn?

Did it result from disease, trauma, or related condition?

Yes No Other

If yes, elaborate

EYE EVALUATION HISTORY

Has your child's vision been previously evaluated?

Yes No Other

If yes, date of last vision exam

Doctor's Name:

Practice Name

Address:

Phone Number

Results and Recommendations:

TREATMENT HISTORY (Please check off each treatment tried.)

Treatment	Diagnosis	Practice Name	Phone Number	Details and satisfaction with results
Glasses
Contacts
Eye Surgery
Patching
Vision Therapy
Atropine Therapy

MEDICAL HISTORY

Doctor's Name	Practice Name
Address	Phone Number
Is your child generally healthy? Yes No	If no, please explain

Previously Diagnosed Conditions (Check all applicable boxes.)

Is there any history of the following?

	Person Affected	Who/Comments		Person Affected	Who/Comments
ADHD	Self Family		High Blood Pressure	Self Family
Genetic Condition	Self Family		Learning Disability	Self Family
Diabetes	Self Family		Thyroid Condition	Self Family
Dyslexia	Self Family		Tubes in Ears	Self Family
Epilepsy / Seizures	Self Family		Other	Self Family

Specialist History

	Specialist Name	Facility Name:	Phone Number:	Results/Recommendations
Neurological Evaluation
Psychological Evaluation
Occupational Therapy Evaluation
Physical Therapy Evaluation
Speech/Hearing Evaluation
Educational Testing

DEVELOPMENTAL HISTORY

Pregnancy and Birth History

Was the child born full-term?

Yes No Other

Any health problems during the pregnancy?

Yes No Other

If yes, what?

Any complications surrounding delivery?

Yes No Other

If yes, what?

Other

Developmental Milestones

Type Of Delay	Please Explain
Movement Developmental Delays
Speech Developmental Delays
Cognitive Developmental Delays
Social Developmental Delays
Other Developmental Concerns

ACADEMIC HISTORY

School Information:

Name of School

Phone

Grade

Address of School

Teacher:

Nurse:

Principal:

Age at entrance to:

Pre-school

Kindergarten

First Grade

Does your child like school? Yes No

Does your child like to read?

What do they like to read?

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

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

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

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

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

Family Member Name	Age	Check if the child lives with the parent.
Mother:
Father:

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:

Type of visit:

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:

Visual History

What is the main reason for today's vision exam?

How long has this problem/difficulty been observed?

Are you here for a second opinion regarding surger or further treatment?

If therapy is recommended, what are your goals?

REFRACTIVE STATUS AND FOCUSING SYMPTOMS

Do you report any of the following?	Yes/No	If yes, how often? 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
Blurred Distance Vision	Yes No Unsure	1 2 3 4
Blurred Near Vision	Yes No Unsure	1 2 3 4
Vision worse at the end of the day	Yes No Unsure	1 2 3 4
Headaches	Yes NO Unsure	1 2 3 4
Eyes hurt or tired after near work	Yes No Unsure	1 2 3 4
Avoids reading or other near tasks	Yes No Unsure	1 2 3 4
Lag in focus	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 repeats lines when reading	Yes No Unsure	1 2 3 4
Loses place while reading	Yes No Unsure	1 2 3 4
Uses finger as a marker	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
Reads Slowly	Yes No Unsure	1 2 3 4
Double Vision	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
Car or motion sickness	Yes No Unsure	1 2 3 4
Poor reading comprehension	Yes No Unsure	1 2 3 4
Does not judge 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
Clumsy, knocks things over	Yes No Unsure	1 2 3 4
Poor / inconsistent in sports	Yes No Unsure	1 2 3 4
Writes or prints poorly	Yes No Unsure	1 2 3 4
Misaligns digits in a column of numbers	Yes No Unsure	1 2 3 4
Writes up / down hill	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
Forgetful / poor memory	Yes No Unsure	1 2 3 4
Misplaces belongings	Yes No Unsure	1 2 3 4
Difficulty attending to details	Yes No Unsure	1 2 3 4

Other Symptoms

Difficulty completing assignments on time	Yes No Unsure	1 2 3 4
Gives up easily	Yes No Unsure	1 2 3 4
Light sensitive	Yes No Unsure	1 2 3 4
Dizziness	Yes No Unsure	1 2 3 4

List any other vision related concerns:

Do you feel your vision interferes with you daily activities in any way?

If yes, explain:

EFFECTIVENESS OF VISION THERAPY (for progress visits only.)

Please describe any new or unresolved concerns since starting therapy.

How has vision therapy improved your life?

May we share your success story with others (first names only)?

Yes No Other

May we share your contact information with prospective therapy students for referral purposes?

Yes No Other

Is There Any History of The Following?

Symptoms	Person Affected	Who/Comments
Amblyopia (Lazy Eye)	Self Family
Blindness	Self Family
Cataract	Self Family
Diabetic Eye Disease	Self Family
Eye Injury	Self Family
Glaucoma	Self Family
Macular Disease	Self Family
Retinal Disease	Self Family
Strabismus	Self Family
None Of The Above	Self Family	Other

Strabismus History

Which eye turns?

Right eye Left Eye Both eyes Unsure Other

Which direction(s) does the eye turn?

In Out Up Down Other

At what age did the turn start?

DId the turn begin gradually or suddenly?

Suddenly Gradually Unsure Other

Is the turn getting better, worse, or no change?

Staying the same Getting worse Getting better Other

Under what circumstances does it turn?

Did it result from disease, trauma, or related condition?

Yes No Other

If yes, elaborate

EYE EVALUATION HISTORY

When was your most recent vision exam?

Doctor's Name:

Practice Name

Address:

Phone Number

Results and Recommendations:

TREATMENT HISTORY (Please check off each treatment tried.)

Treatment	Diagnosis	Practice Name	Phone Number	Details and satisfaction with results
Glasses
Contacts
Eye Surgery
Patching
Vision Therapy
Atropine Therapy

Medical History

Current State Of Health:
Primary Care Doctor's Name: Practice Name:
Address: Phone Number:

Previously Diagnosed Conditions (Check all applicable boxes.)

Is there any history of the following?

	Person Affected	Who/Comments		Person Affected	Who/Comments
ADHD	Self Family		High Blood Pressure	Self Family
Arthritis	Self Family		HIV	Self Family
Chomosomal Imbalance	Self Family		Kidney Disease	Self Family
Cancer	Self Family		Learning Disability	Self Family
Diabetes	Self Family		Lupus	Self Family
Dyslexia	Self Family		Thyroid	Self Family
Epilepsy or Seizures	Self Family		None of the above	Self Family
Heart Disease	Self Family		Other

Specialist History

	Specialist Name	Facility Name:	Phone Number:	Results/Recommendations
Neurological Evaluation
Psychological Evaluation
Occupational Therapy Evaluation
Physical Therapy Evaluation
Speech/Hearing Evaluation
Educational Testing

DEVELOPMENTAL HISTORY

Were you born full term?

Yes No

Did your mother experience any health problems while pregnant with you?	Yes No	If yes, describe
Any complications before, durning, or immediately following your delivery?	Yes No	If yes, describe
Were there ever any concerns about your growth or development?	Yes No	If yes, describe

EDUCATION / EMPLOYMENT INFORMATION

Current Status: Full Time Student Part Time Student Full time Employment Part Time Employment Retired

Current Position:

Describe briefly your daily activities at work or in school:

Please list any specific tasks that you find challenging:

Are you achieving up to your potential at work or school?

yes no not sure Other

Do you feel you are getting adequate return for the amount of effort you put into a task?

yes no not sure Other

Please answer the following if you are in an academic program:
Academic Performance

Area of study:

Overall academic performance is:

above average average below average not sure Other

Please list subjects in school where your performance is above average.

Please list subjects in school where your performance is average.

Please list subjects in school where your performance is below average

Outside Academic Assistance

Have you received any special tutoring and/or remedial assistance?

yes no not sure Other

If yes, how long did the assistance last?

Where did you receive assistance and from whom?

yes no not sure Other

Describe the type and frequency of assistance:

Results of assistance:

HOBBIES / LEISURE TIME

Describe the types of activities that comprise the majority of your spare time.

Are there activities you would like to participate in, but don't?

If yes, which activities and why not?

Computer, Digital Device, and Near Work

How many hours do you spend reading on paper each day?

How many hours do you spend looking at an electronic screen each day?

Do you have a dedicated pair of glasses to view the computer?

How many hours a week do you watch TV?

Do you like to read?

Yes No Other

What do you like to read?

Are you achieving up to your potential at work or school?

yes no not sure Other

If no, why not?

HOME AND FAMILY LIFE

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?