Children Vision Questionnaire Please fill out this questionnaire carefully. Thank you!Child’s Name First Last AgeDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemalePrimary Phone Number*Secondary Phone NumberSchoolGradeTeacherWhom may we thank for referring you?Names of Parents or Legal GuardiansParents or Guardians’ OccupationEmail* Main Concerns/Reason for visitAppointment Location*Progressive Optometry (Panorama) 34 Panatella Blvd NWBrowz Eyeware (Bridgeland) #5, 1010 1st Ave NEAny location: first available appointmentPlease indicate which location your appointment is booked at / or which location you would like your appointment scheduled. MEDICAL HISTORYDoctor’s nameDate of most recent medical examHas a neurological and/or psychological evaluation been performed (please circle)?YesNoList any medicationsList illnesses, bad falls, head injuries, high fevers, etc.Any current or past Occupational, Physical and/or Speech Therapy (please circle)?YesNoDoes your child or relatives have a history of the following?ChildFamilyEye Turn/StrabismusLazy Eye/AmblyopiaHigh PrescriptionLearning DisabilitiesAutism SpectrumADD/ADHDDyslexiaAny other conditions?DEVELOPMENTAL HISTORYPeriod of Pregnancy(weeks)Natural birth or C SectionBirth WeightAny complications before, during or after delivery?TalkAge when child first:SitWalkAny articulation problemsVISUAL HISTORYDate of last eye examName of optometristAge when your child received the first pair of glassesAge of current glassesWere glasses prescribed from last eye exam?YesNoAge of first spectaclesAge of current glassesAre they worn full time or part time?YesNoFor near or distance or both?YesNoACADEMIC HISTORYDoes your child like to read?YesNoVoluntarily?YesNoIs your child performing at, below or above average in school?Has a grade been repeated?YesNoWhich?List any past or current tutoring, Early Childhood Services and/or Individualized Program Planning (IPP)?Please assign a value between 0 and 3 for each symptom0 = symptom not present1 = symptom minimally present2 = symptom moderately present3 = symptom severely presentDouble visionBlurred vision at nearHead tilt or closing one eye when readingHeadaches associated with near workWords run together when readingFalling asleep when readingVision worse at the end of the dayHolding reading material too closeUses finger when readingPoor ability to remember what is readConfuses similar wordsFails to recognize same word in next sentence/pageSkipping or repeating words/lines when readingMis-aligning digits in columns of numbersDifficulty with holding scissors, keysPoor hand writingAvoiding sports and gamesInability to estimate distances accuratelyCar sickness/motion sicknessDifficulty copying from white boardReverses letters, numbers or wordsDifficulty in spellingDifficulty in mathPoor comprehensionAdditional comments you would like us to know