Date

Patients Name*

First Last

Date of Birth

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

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

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

hours

Child's birth weight

lbs. and ozs

Apgar score

@ 1 min

Apgar score

@ 5 min

Mother’s age at child’s birth

Father’s age at child’s birth

Immediately after birth my child was

please specify

Medication prescribed during first year of life

Yes
No

If yes, list meds

DEVELOPMENTAL HISTORY

ACTIVITY / AVERAGE AGE

Gross Motor Development

	EARLY	LATE	NORMAL	UNSURE
Head control / 3 Months
Rolled over / 3.5 Months
Sits w/out support / 6.5 Months
Crawl (stomach on floor) / 7 Months
Creep (stomach off floor)/ 8 Months
Pulls self to stand / 8 Months
Walks unaided/alone / 12 Months
Walks backwards / 14 Months
Kicks a ball / 18 Months
Walks up steps with help / 18 Months
Toilet Trained / 24 Months
Put on some clothing alone / 3 years
Rides tricycle / 3 years

Fine Motor Development

	EARLY	LATE	NORMAL	UNSURE
Eye control 180 degrees /3 Months
Reaches/Grasp for object / 4 Months
Neat pincer grasp / 11 Months
Scribbles spontaneously / 15 Months
Stacks/Piles blocks / 18 Months
Eats with a fork/spoon / 24 Months
Copies circle / 3 years

Language Development

	EARLY	LATE	NORMAL	UNSURE
Smiles spontaneously / 1 Month
Responsive smile / 3-4 Months
Responds to words/ names. / 5 Months
Says single words / 12 Months
Refers to self by first name / 18 Months
Combines 2 different words / 18 Months
Says 2 word sentences / 24 Months
Knows full name / 3 Years

How 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 age

If 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 child

Doctor or Institution

Date

Type of Evaluation

Results/Treatment/Intervention

Doctor or Institution

Date

Type of Evaluation

Results/Treatment/Intervention

Doctor or Institution

Date

Type of Evaluation

Results/Treatment/Intervention

Doctor or Institution

Date

Type of Evaluation

Results/Treatment/Intervention

Check the appropriate spaces if you have any concerns about the following behavior(s) in your child

please explain

NUTRITIONAL INFORMATION

Current Diet

Nursed

Until age

Bottle fed

Solid food started at what age

What 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 PERSON

Is 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 ~