Child Extended Questionnaire Appointment: Day Date MM slash DD slash YYYY Time Patient’s Name: First Last Were you referred to our office Yes No If yes whom may we thank for this referral? Phone Address ac Female No Birth Date: MM slash DD slash YYYY 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 MM slash DD slash YYYY Mother/Caretaker Birth Date MM slash DD slash YYYY ListSiblingBirth Date Add RemoveRESPONSIBLE PERSON INFORMATIONAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneBusiness PhoneFather/Caretaker’s Occupation Business PhoneBusiness Address Street Address City ZIP / Postal Code Mother/Caretaker’s Occupation Business PhoneBusiness Address Street Address City ZIP / Postal Code Do you have Major Medical Insurance? Yes No who is the carrier? Policy # Name of Insured Social Security NumberDriver’s License # MEDICAL HISTORYPediatrician’s Name First Last Date of Last Evaluation MM slash DD slash YYYY For what reason? Results and recommendationsChild’s current state of healthMedications currently using, including vitamins and supplementsFor what condition(s)?Immunizations child has receivedImmunization typeDate Add RemoveAny reactions to immunization(s) Yes No explain List illnesses, bad falls, high fevers, etcAgeSevereMildComplications Add RemoveIs your child generally healthy? Yes No explain Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No please list Add RemoveHas a neurological evaluation been performed? Yes No By whom? Results and recommendations Has a psychological evaluation been performed? Yes No Untitled By whom? Yes No Results and recommendations Yes No Has an occupational therapy evaluation been performed? Yes No By whom? Results and recommendations Is there any history of the following? (Patient) Diabetes “Cross” or “Wall” eye Chromosomal Imbalance Glaucoma High Blood Pressure Learning Disability Amblyopia (lazy eye) Multiple Sclerosis Epilepsy or Seizures Other 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 INFORMATIONCurrent Diet Excellent Good Fair Poor Does your child Like sweets or crave sweets If yes, what types? Is your child active? Yes No extremely? Yes No Are there periods ofvery high energy Yes No very low energy? Yes No Explain DEVELOPMENTAL HISTORYFull-term pregnancy? Yes No Did the mother experience any health problems during the pregnancy? Yes No explain Normal birth? Yes No Any complications before, during or immediately following delivery? Yes No explain Birth weight Apgar scores @ birth After 10 minutes Were forceps used? Yes No Was there ever any reason for concern over your child’s general growth or development? Yes No 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? If not, describe At what age did your child walk? Was child active? Yes No SPEECHFirst words At what age Was early speech clear to others? Yes No Is speech clear now? Yes No VISUAL HISTORYHas your child’s vision been previously evaluated? Yes No Doctor’s Name Date of last evaluation MM slash DD slash YYYY Reason for examination Results and recommendations Were glasses, contact lenses, or other optical devices recommended? Yes No If yes, what? Are they used? Yes No when? why not? Members of the family who have had visual attention and the reasonNameAgeVisual Situation Add RemovePRESENT SITUATIONWhy 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 No 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 Add RemoveHAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING ( If yes, when?)Eyes frequently reddened Frequent eye rubbing Frequent sties 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 ACTIVITIESDoes your child watch TV? Yes No If yes, how much? How often? Viewing distance? Does your child spend time using computer/video games? Yes No 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 explainSCHOOLAge at time of entrance toPre-school Kindergarten First Grade Does your child like school? Yes No Specifically describe any school difficultiesHas your child changed schools often? Yes No If yes, when? Has a grade been repeated? Yes No If yes, which and why? Does your child seem to be under tension or extreme pressure when doing school work? Yes No Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No If yes, when? Where and from whom? How long? Results Does your child like to read? Yes No Voluntarily? Yes No Does your child read for pleasure? Yes No 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 No 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 No Does the teacher feel your child is achieving up to potential? Yes No GENERAL BEHAVIORAre there any behavior problems at school? Yes No If yes, what? Are there any behavior problems at home? Yes No 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 No Is your child in constant motion? Yes No Can your child sit still for long periods? Yes No FAMILY AND HOMEPlease indicate which adult(s) he/she lives with? Mother Father Stepmother Stepfather Foster Parents Adoptive Parents Grandmother Grandfather Aunt Uncle Other Caretaker (please specify Does your child spend time with any other person, not in the home? Yes No Please explain Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)? Yes No If yes, at what age Does your child seem to have adjusted? Yes No Was counseling /therapy undertaken? Yes No If yes, is it on-going? Yes No Is family life stable at this time? Yes No 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 No If yes, who? Did mother or anyone in mother’s family have a learning problem? Yes No If yes, who? Do any, or did any, of the other children in the family have learning problems? Yes No If yes, who? To what extent? GIVE A BRIEF DESCRIPTION OF YOUR CHILD AS A PERSONIS THERE ANY OTHER INFORMATION YOU FEEL WOULD BE HELPFUL/IMPORTANT IN OUR TREATMENT OF YOUR CHILD?RELEASE OF INFORMATION AND INSURANCE FILINGIT IS OFTEN BENEFICIAL TO US TO DISCUSS EXAMINATION RESULTS AND TO EXCHANGE INFORMATION WITH YOUR CHILD’S SCHOOL AND/OR OTHER PROFESSIONALS INVOLVED IN HIS/HER CARE. PLEASE SIGN BELOW TO AUTHORIZE THIS EXCHANGE OF INFORMATION.(Required) I agree to permit information from, or copies of, my child’s examination records to be forwarded to my child’s school, other health care providers or insurance carriers upon their written request or upon the recommendation of PERFORMANCE VISION TRAINING CENTER, when it is necessary for the treatment of my child’s visual condition, or for the processing of insurance claims. I authorize Dr. Jared Pearson and PERFORMANCE VISION TRAINING CENTER to exchange information with my child’s school and other professionals involved in my child’s care, by means of my signature below. This authorization shall be considered valid throughout the duration of treatment.Signature(Required)HiddenDate DD slash MM slash YYYY RELATIONSHIP TO PATIENT Consent I hereby give my permission to PERFORMANCE VISION TRAINING CENTER to treatChild’s Name First Last Parent’s or Guardian’s SignatureThank 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.