Please fill out this questionnaire carefully. Thank you!

Child’s Name

First Last

Age

Date of Birth

Gender

Primary Phone Number*

Secondary Phone Number

School

Grade

Teacher

Whom may we thank for referring you?

Names of Parents or Legal Guardians

Parents or Guardians’ Occupation

Email Address

Main concerns/Reason for visit

MEDICAL HISTORY

Date of most recent medical exam

Doctor’s name

List any medications

List illnesses, bad falls, head injuries, high fevers, etc.

Has a neurological and/or psychological evaluation been performed (please circle)?

Yes
No

Any current or past Occupational, Physical and/or Speech Therapy (please circle)?

Yes
No

Does your child or relatives have a history of the following?

Any other conditions?

DEVELOPMENTAL HISTORY

Period of Pregnancy(weeks)

Natural birth or C Section

Birth Weight

Any complications before, during or after delivery?

Age when child first:

Sit

Walk

Talk

Any articulation problems

VISUAL HISTORY

Date of last eye exam

Name of optometrist

Age when your child received the first pair of glasses

Age of current glasses

Were glasses prescribed from last eye exam?

Yes
No

Age of first spectacles

Age of current glasses

Are they worn full time or part time?

Yes
No

For near or distance or both?

Yes
No

ACADEMIC HISTORY

Does your child like to read?

Yes
No

Voluntarily?

Yes
No

Is your child performing at, below or above average in school?

Has a grade been repeated?

Yes
No

Which?

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 symptom

	0 = symptom not present	1 = symptom minimally present	2 = symptom moderately present	3 = symptom severely present
Double vision
Blurred vision at near
Head tilt or closing one eye when reading
Headaches associated with near work
Words run together when reading
Falling asleep when reading
Vision worse at the end of the day
Holding reading material too close
Uses finger when reading
Poor ability to remember what is read
Confuses similar words
Fails to recognize same word in next sentence/page
Skipping or repeating words/lines when reading
Mis-aligning digits in columns of numbers
Difficulty with holding scissors, keys
Poor hand writing
Avoiding sports and games
Inability to estimate distances accurately
Car sickness/motion sickness
Difficulty copying from white board
Reverses letters, numbers or words
Difficulty in spelling
Difficulty in math
Poor comprehension

	Child	Family
Eye Turn/Strabismus
Lazy Eye/Amblyopia
High Prescription
Learning Disabilities
Autism Spectrum
ADD/ADHD
Dyslexia

Children Vision Questionnaire

MEDICAL HISTORY

DEVELOPMENTAL HISTORY

VISUAL HISTORY

ACADEMIC HISTORY

Panorama Hills (Progressive Optometry)

Bridgeland (Browz Eyeware)

Macleod Trail

Douglasdale – South Trail Crossing