DEVELOPMENTAL HISTORY QUESTIONNAIRE Date MM slash DD slash YYYY Patients Name* First Last Date of Birth MM slash DD slash YYYY School Grade Pediatrician Referral By Whom The reason my child is being examined is general check up other, please explain When did symptoms start: Last eye exam was on MM slash DD slash YYYY Where Glasses: Yes No Age 1st Worn Does your child have any of the following:Eye turns in/out Yes No Explain Squints a lot Yes No Explain Covers/closes one eye a lot Yes No Explain Doesn’t seem to focus Yes No Explain Lacks interest in reading/near activities Yes No Explain Rubs eyes excessively Yes No Explain Eyes burn and itch Yes No Explain Blinks excessively Yes No Explain Reddened or encrusted eyelids Yes No Explain Watery eyes Yes No Explain Eyelid Droop Yes No Explain Poor tracking / eye movements Yes No Explain Head tilt/Face turn Yes No Explain Moves objects very close to look Yes No Explain Double vision Yes No Explain Frequent headaches Yes No Explain Eye pain Yes No Explain Excess light sensitivity Yes No Explain Stares at bright lights or repeatedly Yes No Explain flicks objects in front of face Yes No Explain Stumbles over objects or is clums Yes No Explain Poor motor control Yes No Explain Any eye injury or surgery Yes No Explain Any lazy eye/amblyopia Yes No Explain Any vision therapy/orthoptics Yes No Explain Any patching Yes No Explain Does your child verbalize any problems/ complaints about his/her eyes or vision? Yes No If yes, explain Last medical exam was on Doctor Current 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 specify Length 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 specify Please explain Type of delivery Natural Caesarian Forceps/vacuum Anesthesia other Please specify Were there any problems during delivery? No Yes explain Labor during delivery lasted hoursChild's birth weight lbs. and ozsApgar score @ 1 minApgar score @ 5 minMother’s age at child’s birthFather’s age at child’s birth Immediately 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 specify Medication prescribed during first year of life Yes No If yes, list meds DEVELOPMENTAL HISTORY ACTIVITY / AVERAGE AGE Gross Motor DevelopmentEARLYLATENORMALUNSUREHead 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 DevelopmentEARLYLATENORMALUNSUREEye 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 DevelopmentEARLYLATENORMALUNSURESmiles 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)? Yes No If yes, explain Any problems with colic? Yes No Was there ever any reason for concern over your child’s general growth or development? Yes No If yes, why? Has your child received any special developmental guidance/ assistance? Yes No If yes, explain How many hours daily does your child sleep?Does your child sleep through the night? Yes No If yes, starting at what ageIf no, explain Did your child have a coordinated crawl and creep before he/she walked? Yes No Does your child like to draw/color? Yes No Is your child learning to read? Yes No What 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?Educational Yes No Occupational Yes No Neurological Yes No Speech /Auditory Yes No Psychological Yes No Physical Yes No If yes, please list all previous evaluations done on your childDoctor or Institution Date MM slash DD slash YYYY Type of Evaluation Results/Treatment/Intervention Doctor or Institution Date MM slash DD slash YYYY Type of Evaluation Results/Treatment/Intervention Doctor or Institution Date MM slash DD slash YYYY Type of Evaluation Results/Treatment/Intervention Doctor or Institution Date MM slash DD slash YYYY Type of Evaluation Results/Treatment/Intervention Check 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 explain NUTRITIONAL INFORMATIONCurrent Diet MM slash DD slash YYYY Nursed Until age Bottle fed Solid food started at what ageWhat type? Are there any food allergies/sensitivities? Yes No If yes, what Does 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? Yes No If so, when Are there periods of very low energy? Yes No If so, when GIVE 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.