PVTC Child Strab Questionnaire Please fill out this questionnaire carefully. Appointment Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Patient’s Name First Last GENERAL INFORMATIONWere you referred to our office ? Yes No whom may we thank for this referral? PhoneAddress 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 Child’s Full Name First Last Untitled Male Female Birth Date MM slash DD slash YYYY Age years, monthsName and address of school Grade Teacher School Nurse: Principal: Is your child especially afraid of doctors? Child’s dominant hand Yes No Has guidance been given in use of hand? Yes No 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 Sibling Birth DateNAMEBirth Date Add RemoveRESPONSIBLE PERSON INFORMATIONHome Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone(Required)Business PhoneEmail Father / Caretaker’s Occupation Business Phone:Business Address: Street Address Address Line 2 City ZIP / Postal Code Mother / Caretaker’s Occupation: Business Phone:Business Address: Street Address Address Line 2 City ZIP / Postal Code Do you have Major Medical Insurance? Yes No who is the carrier? Policy #: Name of Insured: Social Security Number: Driver’s License #: MEDICAL HISTORYPediatrician’s Name: First Last Date of Last Evaluation: MM slash DD slash YYYY For what reason? Results and recommendations: Child’s current state of health: Medications currently using, including vitamins and supplements: Is there any history of the following? Glaucoma Diabetes Cataracts Thyroid Condition Blindness High blood pressure Multiple Sclerosis Amblyopia (lazy eye) Brain Tumor Chromosomal Imbalance PatientIs there any Family history of the following?High blood pressure Glaucoma Diabetes Cataracts Thyroid Condition Blindness Multiple Sclerosis Amblyopia (lazy eye) Brain Tumor Chromosomal Imbalance Any history in your family of an eye turn resulting from a disease or other condition? Yes No Other health problems? Yes No please explain: Was there any related trauma, disease, or condition that preceded or accompanied the onset of the eye turn? Yes No please explain: Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No please list: List illnesses, bad falls, high fevers, etc.: Add RemoveAge Severe Mild ComplicationsHas a neurological evaluation been performed? Yes No By whom? Results and recommendations: Has a psychological evaluation been performed? Yes No By whom? Results and recommendations: Has an occupational therapy evaluation been performed? Yes No By whom? Results and recommendations: DEVELOPMENTAL HISTORYFull-term pregnancy? Yes No Did the mother experience any problems during pregnancy? Yes No Normal birth? Yes No Were forceps used? Yes No Any complications before, during or immediately following delivery? Yes No Did your child crawl (stomach on floor)? Yes No At what age? your child creep (stomach off floor)? Yes No At what age? At what age did your child sit up (without support)? At what age did your child walk (without support)? First words: At what age? At what age did your child speak in a simple sentence (string two words together)? Was your child alert as an infant? Yes No Were there ever any concerns regarding growth or development? Yes No explain: NUTRITIONAL INFORMATIONCurrent Diet: Excellent Good Fair Poor Does your child: Like sweets or crave sweets If yes, what types? Are there any food allergies/sensitivities? Yes No If so, explain: Is your child active? Yes No Untitled moderately extremely VISUAL HISTORYAt what age did you first notice or suspect that it was an eye turning? Did the eye begin turning suddenly gradually Does the eye turn (check all that apply) in out up down apply) Is the eye turn getting worse or better, or is there no change? Is it always the same eye that turns? Yes No If yes, which eye? Right Left Is the eye urn always present? Yes No If not, under what conditions is it present? (i.e. when tired, when ill, etc.) Do you notice if the eye turns more when your child is looking: up close? in the distance? to his/her left? to his/her right? up? down? Does one pupil ever appear to be larger than the other? Yes No Do you ever notice one or both eyes shaking rapidly? Yes No Does your child report any of the following:Headaches Blurred vision Double vision Eyes “hurt” or “tired” Motion sickness / car sickness Redness of the eyes List any other complaints your child makes concerning his/her vision:Do you feel your child’s vision hinders his/her daily activities in any way? Yes No how? Have you or anyone else ever noticed the following: Yes No If yes, whenEyes frequently reddened Frequent eye rubbing Frequent styes Frowning Bothered by light Closes or covers an eye Difficulty seeing distant objects Head close to paper when writing Avoids/dislikes reading or other near tasks Tilts head when reading or writing Moves head when reading Confuses letters and words Reverses letters or words Confuses right or left Skips, omits words Loses place when reading Uses finger as marker Poor reading comprehension Comprehension decreases over time Writes or prints poorly Difficulty copying from the chalkboard Tires easily Difficulty with short term memory Difficulty with long term memory Short attention span/loses interest Poor / awkward large motor coordination Poor / awkward fine motor coordination Dislikes/avoids sports Difficulty hitting / catching a ball PREVIOUS TREATMENTSHas your child had a previous visual evaluation? Yes No Doctor’s Name: Date of Last Visit: MM slash DD slash YYYY Results and recommendations: Were glasses, contact lenses, or other optical devices ever prescribed? Yes No If yes Bifocal: Single-vision: Contact lenses: Other Are they used? Yes No If yes, when are they worn? If no, why not? Does the eye turn less when the prescription is worn? Yes No Unsure Has there been any treatment using an eye patch? Yes No If yes, please describe when the patching was started, how the patching was done, including the age it started, the eye patched, the duration of treatment, and an estimate of the results:Have you ever been told that your child has amblyopia (“lazy eye”)? Yes No Has there been any surgical treatment? Yes No If yes, please describe the surgery, including the age surgery was performed, the number of operations, the eye operated on, and an estimate of the cosmetic and subjective results:Were you satisfied with the results of surgery? Yes No Please explain: Was the surgeon satisfied with the results of surgery? Yes No Please explain: Are you here for a second opinion regarding surgery or further treatment? Yes No Has there been any visual therapy? Yes No If yes, Drs. name: NumberIf yes, please describe the type of visual therapy, including its duration, the age at which it started, and an estimate of the results:FAMILY AND HOMEPlease indicate which adult(s) he/she lives with? Father Mother 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: Please give a brief description of your child as a person:Is there any other information that would be important/useful 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, pediatrician, 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 other health care providers or insurance carriers upon their written request or upon the recommendation of the 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. 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.Parent’s or Guardian’s SignatureDate MM slash DD slash YYYY Consent(Required) I hereby give my permission to PERFORMANCE VISION TRAINING CENTER to treat:(Required)Child’s Name(Required) 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 to perform a more comprehensive evaluation of your child and to better meet your child’s specific visual needs If you have any questions or 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. Please do not bring any other children with you because your undivided attention is necessary during the evaluation. THANK YOU. Sincerely, Jared Pearson, O.D.