PRIMITIVE REFLEX Questionaire THIS APPOINTMENT IS 2 HOURS LONG. Please bring or wear shorts and a short-sleeved shirt. Name(Required) First Last Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Age Current Grade/Degree Earned Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If minor, Parent/Guardian Name: First Last Sibling Name(s)/Age(s) Add Remove Home PhoneCell(Required)OtherEmail(Required) 1. Has a diagnosis been identified? (ie: Dyslexia, Dyspraxia, ADHD, ADD) If so, please state: 2. What are the presenting symptoms? 3. What investigations/interventions have been received in the past? 4. List prescribed medication and reason for medication: Add RemovePregnancy/Birth History1. Were you/your child conceived using IVF? Yes No 2. Any known medical problems during pregnancy with a patient? Yes No ie: High blood pressure, excessive vomiting, threatened miscarriage, severe viral infection, etc3. Did the mother smoke while pregnant with the patient? Yes No 4. Did the mother drink alcohol while pregnant with the patient? Yes No 5. Did mother have a bad viral infection in the first 13 weeks of pregnancy? Yes No 6. Was the mother under severe emotional distress at any time, particularly in the first 12 weeks of pregnancy? Yes No 7. Was the patient born approximately at term early for term late for term Please explain: 8. Was the patient birthed vaginally or by cesarean section? Vaginal Birth C-Section 9. Birth Weight: Small size for term? Yes No 10. At birth, was there anything unusual or remarkable noted? le: skull distortion, heavy bruising, blue color/skin tone, heavily jaundiced, covered with a calcium-type coating or require intensive care. If yes, please explain:11. Was eye contact made between mother and baby within the first few minutes of life? Yes No 12. Was the baby placed on the mother's belly to crawl to breast within the first few minutes of life? Yes No Ear, Nose and Throat1. Mouth Ulcers Yes No 2. Bad breath Yes No 3. Tonsillitis Yes No 4. Earache Yes No 5. Sinusitis Yes No 6. Persistent runny nose Yes No 7. Snoring Yes No 8. Mouth breathing Yes No 9. Hay fever Yes No 10. Asthma Yes No Exercise Induced Asthma Yes No Infection Induced Asthma Yes No Dust Induced Asthma Yes No Mold Induced Asthma Yes No Animal Induced Asthma Yes No Food Induced Asthma Yes No Vision1. Have you/your child received a developmental vision exam? Yes No 2. Approximate date of last comprehensive vision exam: MM slash DD slash YYYY 3. Have you/your child participated in a program of vision therapy? Yes No If yes: Prescribed by: Approximate date of vision therapy program: 4. List vision skill concerns: Add RemoveAuditory1. Do you suspect problems processing auditory information? Yes No 2. Have you/your child even been investigated specifically for hearing disabilities? Yes No 3. Do you/your child forget spoken directions quickly? Yes No 4. Do you/your child get distracted by sounds? Yes No 5. Are you/your child oversensitive to sounds? Yes No 6. Do you/your child misinterpret conversations? Yes No 7. Do you/your child confuse similar sounding words? Yes No 8. Do you/your child need things to be repeated often? Yes No 9. Do you/your child have difficulty following sequential instructions? Yes No 10. Have you/your child received any auditory training? Yes No If yes, which program? Did the auditory processing program use bone conduction? Yes No 11. Do you/your child have any of the following:Hesitant speech Yes No Flat and monotonous voice Yes No Weak vocabulary Yes No Poor sentence structure Yes No Inability to sing in tune Yes No Confusion or reversal of letters Yes No Poor reading comprehension Yes No Poor reading aloud Yes No Poor spelling Yes No Check skills you are hoping to develop/improve Interest in exercise/training Confidence Sitting still Waiting quietly Reading without losing place Understand directions Sports performance Telling time Comprehension Balance Eye control/convergence Eye teaming Knowing right from left Spelling Coordination Math Writing Attention Toileting Interest in School Speech Decreased reversals Muscle tone Alertness/energy level Social skills Listening Decreased irritability Motivation Sleeping Other please list PVTC Video and Photo Release AgreementConsent(Required) | agree to allow video or photographs to be taken of me/my child for reference purposes as a means of evaluating performance and documenting progress. The Performance Vision Training Center Team may use the images for the following:(Required)● Evaluation Purposes ● Professional presentations and or publications for Parents, Therapists, Doctors, and/or Educators. These presentations occur at local, state, national and international conferences. ● Brochures or other Marketing Resources. ● Motivational Awards (Including graduation/completion of program Award). ● The Vision Development Team's Website, Facebook page, and Newsletter ● Binovi App Training videos that can be viewed by other patients at our practiceConsent(Required) I understand that my/my child's last name or personal information will not be used.(Required)Signature of Patient/Parent(Required)Consent OPT OUT - I choose to opt out of PVTC”s Video and Photo Release AgreementSignature of Patient/Parent