Child Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.About You - Step 1 of 7Child's/Student's Name *FirstLastDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address (or school address if being filled in by teacher) *Address Line 1CityState / Province / RegionPostal CodePhone *Email *Parent's/Guardian Name (1) *FirstLastParent's/Guardian Name (2) *FirstLastDate and Time of our Appointment (if booked)DateTimeNextReason for ReferralWho recommended that your child be seen by a behavioural optometrist?Why?What do you feel are your child's main difficulties and your concerns?Which school does your child attend?Have your child's school expressed any concerns about his/her progress, if so what?Have any other tests been carried out by SENCo/Educational Psychologist/Occupational Therapist/ Speech and Language therapist?YesNo Please give more dates, details and send me a copy of report to read before appointmentAre there any other factors, or further information you feel would be of help to us?PreviousNextDevelopmental HistoryWere there any complications or difficulties during pregnancy or at birth?If yes, please give details.Was your child born by caesarean section?YesNoWas birth premature?YesNoWas birth weight low?YesNoHas your child had/have problems with glue ear or grommets used?Do you feel your child has a hearing problem or finds sequences of instructions difficult to follow?Does your child have any health problems?If yes, please give details, especially regarding concussions.Does your child suffer from any allergies?If yes, please give details.At what age did your child crawl, and was crawling normal?At what age did your child walk?At what age did your child talk? Is your child right/left handed or ambidextrous?Right HandedLeft HandedAmbidextrousAre you concerned about their attention levels and or is ADHD or ADD a suspicion? If yes, please give details.Is there any history of learning or reading problems, Aspergers or other autism, dyspraxia in the close family?PreviousNextVisual HistoryDoes your child have spectacles?YesNoIf yes, email a copy of prescription prior to our appointment.When was their last eye examination? Have they needed to see the hospital or orthoptist about their eyes?YesNoPlease give details:Is there any close family history of spectacles or a lazy eye?YesNoPlease give details:PreviousNextVisual Symptoms ChecklistPlease indicate below the frequency of their symptoms. If never, please leave blank.ReadingDifficulty keeping placeOccasionallyFrequentlySkips or rereads linesOccasionallyFrequentlyOmits wordsOccasionallyFrequentlyConfuses word, letter or number orderOccasionallyFrequentlyWord by word readingOccasionallyFrequentlyDifficulty remembering what they have readOccasionallyFrequentlyTilts or turns headOccasionallyFrequentlyPoor sitting postureOccasionallyFrequentlyHolds head close to the pageOccasionallyFrequentlyCloses or covers one eyeOccasionallyFrequentlyRubs eyes during or after readingOccasionallyFrequentlyProblems with 3D movies or TV? - Fatigue/removing 3D spectacles/rubbing eyes/cannot watch them/cannot see the 3DOccasionallyFrequentlyShort attention spanOccasionallyFrequentlyAvoids readingOccasionallyFrequentlyReverses words, letters and/or numbersOccasionallyFrequentlyComplaints of letters movingOccasionallyFrequentlyComplaints of letters fading/shimmeringOccasionallyFrequentlyComplaints of colours around letters/wordsOccasionallyFrequentlyComplaints of letters shadowing or doubling OccasionallyFrequentlyPreviousNextVisual Symptoms ChecklistPlease indicate below the frequency of your symptoms.Body Posture and Space Awareness:Unusual Awkwardness OccasionallyFrequentlyFrequent tripping and stumblingOccasionallyFrequentlyKnocks things off table/deskOccasionallyFrequentlyDifficulty with catching/throwingOccasionallyFrequentlyConfuses right and leftOccasionallyFrequentlyGeneral Behaviour:Avoiding close workOccasionallyFrequentlyDistractibleOccasionallyFrequentlyUnusual fatigue after close workOccasionallyFrequentlyTension during close work, including hunching over or wrigglingOccasionallyFrequentlyHeadaches during/after close workOccasionallyFrequentlyWriting and Other Desk TasksDifficulty copying from the boardOccasionallyFrequentlyOmits words or phrasesOccasionallyFrequentlyRepeating words or phrasesOccasionallyFrequentlyConfusing the order of letters and/or numbersOccasionallyFrequentlyPoor handwritingOccasionallyFrequentlyDifficulty staying on the lineOccasionallyFrequentlyWriting neatly, but slowlyOccasionallyFrequentlyReversing letters or numbersOccasionallyFrequentlyHolding head too close to the pageOccasionallyFrequentlyTilting head to one sideOccasionallyFrequentlyPreviousNextAny further information:PreviousWebsiteSubmit
