DEVELOPMENTAL HISTORY QUESTIONNAIRE Date Date Format: MM slash DD slash YYYY Patients Name* First Last Date of Birth Date Format: MM slash DD slash YYYY SchoolGradePediatricianReferral By WhomThe reason my child is being examined is general check up other, please explain When did symptoms start:Last eye exam was on Date Format: MM slash DD slash YYYY WhereGlasses: Yes No Age 1st WornDoes your child have any of the following:Eye turns in/out Yes No ExplainSquints a lot Yes No ExplainCovers/closes one eye a lot Yes No ExplainDoesn’t seem to focus Yes No ExplainLacks interest in reading/near activities Yes No ExplainRubs eyes excessively Yes No ExplainEyes burn and itch Yes No ExplainBlinks excessively Yes No ExplainReddened or encrusted eyelids Yes No ExplainWatery eyes Yes No ExplainEyelid Droop Yes No ExplainPoor tracking / eye movements Yes No ExplainHead tilt/Face turn Yes No ExplainMoves objects very close to look Yes No ExplainDouble vision Yes No ExplainFrequent headaches Yes No ExplainEye pain Yes No ExplainExcess light sensitivity Yes No ExplainStares at bright lights or repeatedly Yes No Explainflicks objects in front of face Yes No ExplainStumbles over objects or is clums Yes No ExplainPoor motor control Yes No ExplainAny eye injury or surgery Yes No ExplainAny lazy eye/amblyopia Yes No ExplainAny vision therapy/orthoptics Yes No ExplainAny patching Yes No ExplainDoes your child verbalize any problems/ complaints about his/her eyes or vision? Yes No If yes, explainLast medical exam was onDoctorCurrent medications (dose & reason for taking)Immunizations up to date Yes No Any Reactions to Immunizations:PREGNANCY/ BIRTH HISTORY:My child is: natural adopted foster other Please specifyLength of pregnancy less than 7 mos 7- 8 mos 8-9 mos over 9 mos During pregnancy of this child, which, if any, of the following occurred toxemia trauma use of alcohol injury by fall smoking use of drugs severe illness prescribed medication little obstetrical care other Please specifyPlease explainType of delivery Natural Caesarian Forceps/vacuum Anesthesia other Please specifyWere there any problems during delivery?NoYesexplainLabor during delivery lastedhoursChild's birth weight lbs. and ozsApgar score@ 1 minApgar score @ 5 minMother’s age at child’s birthFather’s age at child’s birthImmediately after birth my child was given oxygen allergic running a fever having breathing/feeding problems jaundiced doing well, requiring no medical treatment placed in incubator having Rh problems placed in neonatal ICU other please specifyMedication prescribed during first year of lifeYesNoIf yes, list medsDEVELOPMENTAL HISTORY ACTIVITY / AVERAGE AGE Gross Motor DevelopmentEARLYLATENORMALAgreeUNSUREHead control / 3 MonthsRolled over / 3.5 MonthsSits w/out support / 6.5 MonthsCrawl (stomach on floor) / 7 MonthsCreep (stomach off floor)/ 8 MonthsPulls self to stand / 8 MonthsWalks unaided/alone / 12 MonthsWalks backwards / 14 MonthsKicks a ball / 18 MonthsWalks up steps with help / 18 MonthsToilet Trained / 24 MonthsPut on some clothing alone / 3 yearsRides tricycle / 3 yearsFine Motor DevelopmentEARLYLATENORMALAgreeUNSUREEye control 180 degrees /3 MonthsReaches/Grasp for object / 4 MonthsNeat pincer grasp / 11 MonthsScribbles spontaneously / 15 MonthsStacks/Piles blocks / 18 MonthsEats with a fork/spoon / 24 MonthsCopies circle / 3 yearsLanguage DevelopmentEARLYLATENORMALAgreeUNSURESmiles spontaneously / 1 MonthResponsive smile / 3-4 MonthsResponds to words/ names. / 5 MonthsSays single words / 12 MonthsRefers to self by first name / 18 MonthsCombines 2 different words / 18 MonthsSays 2 word sentences / 24 MonthsKnows full name / 3 YearsHow is your child performing as compared to others his/her age Above average Below average Were there any difficulties at all in feeding (such as difficulty with sucking, vomiting)?YesNoIf yes, explainAny problems with colic?YesNoWas there ever any reason for concern over your child’s general growth or development?YesNoIf yes, why?Has your child received any special developmental guidance/ assistance?YesNoIf yes, explainHow many hours daily does your child sleep?Does your child sleep through the night?YesNoIf yes, starting at what ageIf no, explainDid your child have a coordinated crawl and creep before he/she walked?YesNoDoes your child like to draw/color?YesNoIs your child learning to read?YesNoWhat things can your child do very well?What things, if any, are difficult for your child?What difficulties are your child experiencing in school?Has your child undergone any of the following testing/treatment?EducationalYesNoOccupationalYesNoNeurologicalYesNoSpeech /AuditoryYesNoPsychologicalYesNoPhysicalYesNoIf yes, please list all previous evaluations done on your childDoctor or InstitutionDate Date Format: MM slash DD slash YYYY Type of EvaluationResults/Treatment/InterventionDoctor or InstitutionDate Date Format: MM slash DD slash YYYY Type of EvaluationResults/Treatment/InterventionDoctor or InstitutionDate Date Format: MM slash DD slash YYYY Type of EvaluationResults/Treatment/InterventionDoctor or InstitutionDate Date Format: MM slash DD slash YYYY Type of EvaluationResults/Treatment/InterventionCheck the appropriate spaces if you have any concerns about the following behavior(s) in your child Lack of curiosity Thumb-sucking Nervous Glum, sulky, mood Bad temper Passive Irritable, easily upset Restlessness Has difficulty separating from parents Sleeplessness Lethargic, low energy Aggressive Other please explainNUTRITIONAL INFORMATIONCurrent Diet Date Format: MM slash DD slash YYYY Nursed Until age Bottle fed Solid food started at what ageWhat type?Are there any food allergies/sensitivities?YesNoIf yes, whatDoes your child Like sweets Crave sweets If so, what?What are his/her favorite foods?What are his/her disliked/avoided foods?Activity Level High Moderate Low Are there periods of very high energy?YesNoIf so, whenAre there periods of very low energy?YesNoIf so, whenGIVE A BRIEF DESCRIPTION OF YOUR CHILD AS A PERSONIs there any other information that would be helpful/important in our evaluation or treatment of your child?Name of Parent / Guardian First Last Name of Parent / Guardian First Last Phone(In case Doctor has questions)Email Thank you for carefully completing this questionnaire. This will enable us to perform a more comprehensive evaluation and to better meet your child’s specific visual needs. Please bring toys or books your child enjoys. ~ Thank You ~ Print, fill out and bring the Developmental History Questionnaire to the practice.