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Demographics

Personal Information
Title First Last MI Suffix Nickname
Address:

City:
State/ZipCode
Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status
Employed Full-Time Student
Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing InformationIs The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Pediatric VT History

Children's Vision Questionnaire-Extended Form



Type Of Visit:

Type of Visit Date

CHILD INFORMATION
Child's Full Name Gender
Date of Birth
Age:Years Months
Has guidance been given in use of hand? Child's dominant hand


General Information


REFERRAL INFORMATION
How did you hear about us?
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?
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
Blurred near vision
Vision worse at the end of the day
Headaches
Eyes "hurt" or "tired" after near work
Avoids reading or other near tasks
Lag in focus

Ocular Mobility Symptoms
Moves head when writing or reading
Skips or repeats lines when reading
Loses place while reading
Uses finger as a marker

Eye Teaming (Binocularity Symptoms)
Closes or covers an eye
Tilts head when reading or writing
Reads slowly
Double vision
Words move around on the page
Words run togehter when reading
Car or motion sickness
Poor reading comprehension
Does not judge distance accurately

Eye-Hand Coordination Symptoms
Poor / awkward large motor coordination
Poor/ awkward fine motor coordination
Clumsy, knocks things over
Poor / inconsistent in sports
Knows material but does poorly on tests
Writes poorly or slowly
Difficulty copying from the chalkboard
Misalign digits in a column of numbers
Writing slants up or downhill
Cannot stay on our between ruled lines

Visual Perception Symptoms
Confuses right and left
Confuses letters or words
Reverses letters or words
Reverses letters or words
Forgetful / poor memory
Trouble following directions
Difficulty recognizing same word on a different page
Misplaces belongings
Can't spell known sight words
Difficulty attending to details
Vocalizes when reading silently

Other Symptoms
Says "I can't" before trying
Difficulty completing tasks on time
Bothered by light
Dizziness

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

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?
Which direction(s) does the eye turn?
At what age did the turn start?
Did the turn begin gradually or suddenly?
Is the turn getting better, worse, or no change?
Under what circumstances does it turn?
Did it result from disease, trauma, or related condition?
If yes, elaborate

EYE EVALUATION HISTORY
Has your child's vision been previously evaluated?
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.)
TreatmentDiagnosisPractice NamePhone NumberDetails and satisfaction with results
Glasses
Contacts
Eye Surgery
Patching
Vision Therapy
Atropine Therapy

MEDICAL HISTORY


Doctor's Name Practice Name
AddressPhone Number
Is your child generally healthy? If no, please explain

Previously Diagnosed Conditions (Check all applicable boxes.) Is there any history of the following?
Person AffectedWho/CommentsPerson AffectedWho/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?
Any health problems during the pregnancy? If yes, what?
Any complications surrounding delivery? If yes, what?

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?
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?
If yes, which schools and why? Please explain
Has a grade been repeated?
If yes, which grade(s) repeated and why? Please explain
Does your child seem to be under tension or extreme pressure when doing schoolwork?
What is your child's attitude toward reading, school, his/her teachers, other youngsters? Please explain
Overall academic performance is:

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?
Do you feel that your child is achieving up to potential?
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?
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?
If yes, what are the behavior problems at school? Please explain
Are there any behavior problems at home?
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?
What are your child's reaction to tension?
Does your child say and / or do things impulsively?
Is your child in constant motion?
Can your child sit still for long periods?

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?
Was counseling and / or therapy involved with the traumatic situation?
If there was counseling and / or therapy, is it on-going?
Is the family life stable at this time?
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? 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
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
Blurred Near Vision
Vision worse at the end of the day
Headaches
Eyes hurt or tired after near work
Avoids reading or other near tasks
Lag in focus

Ocular Mobility Symptoms
Moves head when writing or reading
Skips or repeats lines when reading
Loses place while reading
Uses finger as a marker

Eye Teaming (Binocularity Symptoms)
Closes or covers an eye
Tilts head when reading or writing
Reads Slowly
Double Vision
Words move around on the page
Words run together when reading
Car or motion sickness
Poor reading comprehension
Does not judge distance accurately

Eye-Hand Coordination Symptoms
Poor / awkward large motor coordination
Poor/ awkward fine motor coordination
Clumsy, knocks things over
Poor / inconsistent in sports
Writes or prints poorly
Misaligns digits in a column of numbers
Writes up / down hill

Visual Perception Symptoms
Confuses letters or words
Reverses letters or words
Forgetful / poor memory
Misplaces belongings
Difficulty attending to details

Other Symptoms
Difficulty completing assignments on time
Gives up easily
Light sensitive
Dizziness
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 child's life?
May we share your success story with others (first names only)?
May we share your contact information with prospective therapy students for referral purposes?

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?
Which direction(s) does the eye turn?
At what age did the turn start?
DId the turn begin gradually or suddenly?
Is the turn getting better, worse, or no change?
Under what circumstances does it turn?
Did it result from disease, trauma, or related condition?
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.)
TreatmentDiagnosisPractice NamePhone NumberDetails 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 AffectedWho/CommentsPerson AffectedWho/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?
Did your mother experience any health problems while pregnant with you? If yes, describe
Any complications before, durning, or immediately following your delivery? If yes, describe
Were there ever any concerns about your growth or development? 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?

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

Please answer the following if you are in an academic program:
Academic Performance
Area of study:
Overall academic performance is:

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?
If yes, how long did the assistance last?
Where did you receive assistance and from whom?
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?
What do you like to read?

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

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Precision Eye Care updated 11-17-2013 rev. 38