Child Extended Questionnaire

Appointment: Day

Date

Time

Patient’s Name:

First Last

Were you referred to our office

Yes

If yes whom may we thank for this referral?

Phone

Address

Female

Birth Date:

Age:

Name and address of school:

Grade:

Teacher:

School Nurse:

Principal:

Is your child especially afraid of doctors?

Child’s dominant hand

right

left?

Please list the names and birth dates of your family:

Father/Caretaker

Birth Date

Mother/Caretaker

Birth Date

List

Sibling

Birth Date

RESPONSIBLE PERSON INFORMATION

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Business Phone

Father/Caretaker’s Occupation

Business Phone

Business Address

Street Address City ZIP / Postal Code

Mother/Caretaker’s Occupation

Business Phone

Business Address

Street Address City ZIP / Postal Code

Do you have Major Medical Insurance?

Yes

who is the carrier?

Policy #

Name of Insured

Social Security Number

Driver’s License #

MEDICAL HISTORY

Pediatrician’s Name

First Last

Date of Last Evaluation

For what reason?

Results and recommendations

Child’s current state of health

Medications currently using, including vitamins and supplements

For what condition(s)?

Immunizations child has received

Immunization type

Date

Any reactions to immunization(s)

Yes

explain

List illnesses, bad falls, high fevers, etc

Age

Severe

Mild

Complications

Is your child generally healthy?

Yes

explain

Are there any chronic problems like ear infections, asthma, hay fever, allergies?

Yes

please list

Has a neurological evaluation been performed?

Yes

By whom?

Results and recommendations

Has a psychological evaluation been performed?

Yes

Untitled

By whom?

Yes

Results and recommendations

Yes

Has an occupational therapy evaluation been performed?

Yes

By whom?

Results and recommendations

Is there any history of the following? (Patient)

please explain

Is there any Family history of the following?

Diabetes

“Cross” or “Wall” eye

Chromosomal Imbalance

Glaucoma

High Blood Pressure

Learning Disability

Amblyopia (lazy eye)

Multiple Sclerosis

Epilepsy or Seizures

Other. please explain

NUTRITIONAL INFORMATION

Current Diet

Excellent

Good

Fair

Poor

Does your child

Like sweets

or crave sweets

If yes, what types?

Is your child active?

Yes

extremely?

Yes

Are there periods of

very high energy

Yes

very low energy?

Yes

Explain

DEVELOPMENTAL HISTORY

Full-term pregnancy?

Yes

Did the mother experience any health problems during the pregnancy?

Yes

explain

Normal birth?

Yes

Any complications before, during or immediately following delivery?

Yes

explain

Birth weight

Apgar scores @ birth

After 10 minutes

Were forceps used?

Yes

Was there ever any reason for concern over your child’s general growth or development?

Yes

why?

Did your child crawl (stomach on floor)?

Yes

At what age?

Did your child creep (on all fours)?

Yes

At what age?

If not, describe

At what age did your child walk?

Was child active?

Yes

SPEECH

First words

At what age

Was early speech clear to others?

Yes

Is speech clear now?

Yes

VISUAL HISTORY

Has your child’s vision been previously evaluated?

Yes

Doctor’s Name

Date of last evaluation

Reason for examination

Results and recommendations

Were glasses, contact lenses, or other optical devices recommended?

Yes

If yes, what?

Are they used?

Yes

when?

why not?

Members of the family who have had visual attention and the reason

Name

Age

Visual Situation

PRESENT SITUATION

Why 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

what?

Does your child report any of the following? (If yes, when?)

Headaches

Blurred vision / focus goes in and out

Double vision

Eyes hurt

Eyes tired

Words move around on the page

Motion sickness / car sickness

Dizziness

List any other complaints your child makes concerning his/her vision

HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING ( If yes, when?)

Eyes frequently reddened

Frequent eye rubbing

Frequent sties

Bothered by light

Frequent blinking

Closing or covering one eye

Difficulty seeing distant objects

Head close to paper when reading or 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 right and lef

Skips, rereads or omits words

Loses place while reading

Vocalizes when reading silently

Reads slowly

Uses finger as a marker

Poor reading comprehension

Comprehension decreases over time

Writes or prints poorly

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 on different page

Poor word attack skills

Difficulty with memory

Remembers better what hears than sees

Responds better orally than by writing

Seems to know material, but does poorly on tests

Dislikes / avoids near tasks

Short attention span / loses interest

Poor large motor coordination

Poor fine motor coordination

Difficulty with scissors / small hand tools

Dislikes / avoids sports

Difficulty catching / hitting a ball

TELEVISION VIEWING/LEISURE TIME ACTIVITIES

Does your child watch TV?

Yes

If yes, how much?

How often?

Viewing distance?

Does your child spend time using computer/video games?

Yes

If yes, how much?

How often?

Viewing distance?

What other activities occupy your child’s leisure time?

Are there any activities your child would like to participate in, but doesn’t?

Please explain

SCHOOL

Age at time of entrance to

Pre-school

Kindergarten

First Grade

Does your child like school?

Yes

Specifically describe any school difficulties

Has your child changed schools often?

Yes

If yes, when?

Has a grade been repeated?

Yes

If yes, which and why?

Does your child seem to be under tension or extreme pressure when doing school work?

Yes

Has your child had any special tutoring, therapy, and/or remedial assistance?

Yes

If yes, when?

Where and from whom?

How long?

Results

Does your child like to read?

Yes

Voluntarily?

Yes

Does your child read for pleasure?

Yes

What does your child like to read?

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

Overall schoolwork is

above average

average

below average

WHICH SUBJECTS ARE Above average

WHICH SUBJECTS ARE Average

WHICH SUBJECTS ARE Below average:

Does your child need to spend a lot of time/effort to maintain this level of performance?

Yes

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

To what extent do you assist your child with homework?

Do you feel your child is achieving up to potential?

Yes

Does the teacher feel your child is achieving up to potential?

Yes

GENERAL BEHAVIOR

Are there any behavior problems at school?

Yes

If yes, what?

Are there any behavior problems at home?

Yes

If yes, what?

What causes these problems?

Child’s reaction to fatigue?

sag

irritable

Other

Child’s reaction to tension?

avoidance

irritable

Other

Does your child say and/or do things impulsively?

Yes

Is your child in constant motion?

Yes

Can your child sit still for long periods?

Yes

FAMILY AND HOME

Please indicate which adult(s) he/she lives with?

(please specify

Does your child spend time with any other person, not in the home?

Yes

Please explain

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

Yes

If yes, at what age

Does your child seem to have adjusted?

Yes

Was counseling /therapy undertaken?

Yes

If yes, is it on-going?

Yes

Is family life stable at this time?

Yes

If no, please explain

How does your child get along with: Parents/other caretakers?

How does your child get along with: Siblings?

How does your child get along with: Classmates in school?

How does your child get along with: Playmates at home?

Did father or anyone in father’s family have a learning problem?

Yes

If yes, who?

Did mother or anyone in mother’s family have a learning problem?

Yes

If yes, who?

Do any, or did any, of the other children in the family have learning problems?

Yes

If yes, who?

To what extent?

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?

RELEASE OF INFORMATION AND INSURANCE FILING

Signature(Required)

Hidden

Date

RELATIONSHIP TO PATIENT

Child’s Name

First Last

Parent’s or Guardian’s Signature

Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us perform a more comprehensive evaluation of your child and to better meet your child’s specific visual needs.

If you have any questions on concerns that we may answer prior to your appointment, please do not hesitate to contact us.

You may leave a message for us 24 hours a day /7 days a week. We request a minimum of 24 hours notice if you are unable to keep this appointment.

Please be on time for your examination, so that we will have the maximum opportunity to evaluate your child’s visual status.

THANK YOU.
SINCERELY,
DR. JARED PEARSON, O.D.

RESPONSIBLE PERSON INFORMATION

MEDICAL HISTORY

NUTRITIONAL INFORMATION

DEVELOPMENTAL HISTORY

SPEECH

VISUAL HISTORY

PRESENT SITUATION

TELEVISION VIEWING/LEISURE TIME ACTIVITIES

SCHOOL

GENERAL BEHAVIOR

FAMILY AND HOME

RELEASE OF INFORMATION AND INSURANCE FILING

Vision Source Specialists