PVTC Child Strab Questionnaire

Please fill out this questionnaire carefully.

Appointment

Date

Time

Patient’s Name

First Last

GENERAL INFORMATION

Were you referred to our office ?

Yes

whom may we thank for this referral?

Phone

Address

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

Child’s Full Name

First Last

Untitled

Male

Female

Birth Date

Age

years, months

Name and address of school

Grade

Teacher

School Nurse:

Principal:

Is your child especially afraid of doctors?

Child’s dominant hand

Yes

Has guidance been given in use of hand?

Yes

Please list the names and birth dates of your family:

Father/Caretaker Birth Date

Mother/Caretaker Birth Date

Sibling Birth Date

NAME

Birth Date

RESPONSIBLE PERSON INFORMATION

Home Address:

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

Home Phone(Required)

Business Phone

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

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:

Is there any history of the following?

Patient

Is 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

DEVELOPMENTAL HISTORY

Full-term pregnancy?

Yes

Did the mother experience any problems during pregnancy?

Yes

Normal birth?

Yes

Were forceps used?

Yes

Any complications before, during or immediately following delivery?

Yes

Did your child crawl (stomach on floor)?

Yes

At what age?

your child creep (stomach off floor)?

Yes

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

Were there ever any concerns regarding growth or development?

Yes

explain:

NUTRITIONAL INFORMATION

Current Diet:

Excellent

Good

Fair

Poor

Does your child:

Like sweets

or crave sweets

If yes, what types?

Are there any food allergies/sensitivities?

Yes

If so, explain:

Is your child active?

Yes

Untitled

moderately

extremely

VISUAL HISTORY

At 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)

out

down

apply) Is the eye turn getting worse or better, or is there no change?

Is it always the same eye that turns?

Yes

If yes, which eye?

Right

Left

Is the eye urn always present?

Yes

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

Do you ever notice one or both eyes shaking rapidly?

Yes

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

how?

Have you or anyone else ever noticed the following:
Yes No If yes, when

Eyes 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 TREATMENTS

Has your child had a previous visual evaluation?

Yes

Doctor’s Name:

Date of Last Visit:

Results and recommendations:

Were glasses, contact lenses, or other optical devices ever prescribed?

Yes

If yes

Bifocal:

Single-vision:

Contact lenses:

Other

Are they used?

Yes

If yes, when are they worn?

If no, why not?

Does the eye turn less when the prescription is worn?

Yes

Unsure

Has there been any treatment using an eye patch?

Yes

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

Has there been any surgical treatment?

Yes

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

Please explain:

Was the surgeon satisfied with the results of surgery?

Yes

Please explain:

Are you here for a second opinion regarding surgery or further treatment?

Yes

Has there been any visual therapy?

Yes

If yes, Drs. name:

Number

If 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 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:

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 FILING

It 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 Signature

Date

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 Signature

Thank 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.

Appointment

GENERAL INFORMATION

Please list the names and birth dates of your family:

RESPONSIBLE PERSON INFORMATION

MEDICAL HISTORY

DEVELOPMENTAL HISTORY

NUTRITIONAL INFORMATION

VISUAL HISTORY

PREVIOUS TREATMENTS

FAMILY AND HOME

RELEASE OF INFORMATION AND INSURANCE FILING

Vision Source Specialists