6-18 Years

Behavioral Optometry, Ltd.
5
6-18 years

6-18 Years INTAKE FORM QUESTIONAIRE.

Step 1/8:

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A) General information

Child's name *

Date of Birth *

Appointment Date *

Appointment Time *

Child's Handedness *

Left

Right

Referred By *

Home Address (Please include City, State and Zip Code) *

Contact Phone Number *

Contact Email *

Name of Child's School *

Child's Grade *

Your Name *

Your Occupation *

Business Phone *

Spouse's Name *

Spouse's Occupation *

Brother/Sister (please include DOB) *

B) Signs of Vision Dysfunction

SIGHT is seeing clearly. 20/20 is just a measurement of sight or visual acuity/clarity.
VISION is taking in information, organizing it, and then doing something with it, i.e. perceiving, processing and performance. We separate visual perception, visual motor, visual auditory integration, visual-vestibular integration, visualization, eye movements, etc. from vision to understand vision, but they are all part of the overall process of vision directly governed or impacted by how we perceive, process and perform through our vision.

Please check all below that apply.

Difficulty with eye movements

Often loses place while reading or doing math problems

Prefers to touch things rather than just observe to gather information

Uses finger or marker to keep place when reading

Difficulty coordinating the information from each eye with thinking, movement, speaking and listening

Sensitive to or bothered by bright lights; will squint, cover eyes, eyes will water and/or get headaches

Difficulty concentrating in colorful rooms or dimly lit rooms

Prefers playing in the dark

Difficulty with consistent spacing and size of letters during writing

Rubs eyes, has watery eyes or gets headaches after reading or watching TV

Difficulty keeping eyes focused on task/activity he/she is working on for an appropriate amount of time

Easily distracted by other visual stimuli in the room, i.e. movement, decorations, toys, windows, etc.

Avoids eye contact

Complains of “seeing double”, words popping or moving off page, or words running together

Difficulty with consistent spacing and size of letters during writing

Tends to write at a slant (up or down hill) on a page

Messy/clumsy writing

Difficulty cutting/tracing along a lime

Difficulty lining up numbers in math problems

Fatigues easily with schoolwork, reading or computer reading tasks

Prefers learning auditorily instead of reading and/or studying

Poor reading comprehension skills

Rereads to understand

Slow reading

Difficulty judging spatial relationships in the environment, i.e., bumps into objects/ people or missteps on curbs or stairs

Difficulty with catching, throwing, hitting or kicking a ball

Poor timing at sports, e.g. when and where to catch or hit the ball

Mismatches in space, e.g. spills or knocks things over

Poor rhythm

Visual signs or symptoms indicating tunneling (One centers on a target or detail and ignores all other sensory input. This becomes more difficult to do under certain situations – tunneling in dynamic scenarios or multiple conversations leads to one becoming overwhelmed.)

Hard time seeing the “big picture”, i.e. focuses on the details or becomes sidetracked

Difficulty locating items among other items, i.e. papers on a desk, clothes in a drawer, items on a grocery shelf, toys in a box

Often loses place when copying from a book or whiteboard

Difficulty controlling eye movement to track and follow moving objects

Often unaware or inattentive to surroundings

Needs to be called several times to get attention when watching TV, playing video games, etc.

Goes off on tangents in conversations

Prefer playing and interacting with one to two others rather than a group

Poor organizational skills – loses things, poor planner, doesn’t put things away

Cannot find things in plain sight

Prefers individual sports, e.g. biking, hiking

Difficulty staying present in conversations, i.e. mind wanders

A step behind the action in team sports

Fragmenting (seeing the world in small chunks as opposed to the bigger picture)

Difficulty following multiple directions

Reads with pauses or hesitations, i.e. robotic manner

Lack of general fluidity, i.e. hesitations or pauses when doing sequential activities or movements

Signs and symptoms indicating visual perceptual/organizational inadequacies

Difficulty telling the difference between similar printed letters/figures, i.e. p & q, b & d, + & x or square & rectangle

Makes reversals in words or letters when copying, or reads words backwards, i.e. “was” for “saw” and “no” for “on” after first grade

Difficulty telling the difference between different colors, shapes and sizes

Difficulty finding differences in pictures, words, symbols or objects

Difficulty with jigsaw puzzles and copying shapes

Confuse spatial directions, e.g. left and right

Difficulty telling stories in proper sequence

Physical symptoms indicating visual distress

Complains of headaches with reading or computer tasks

General fatigue following reading, writing or computer tasks

Neck, shoulder or upper back tension

Eyes not fully open

Eye turn

Head tilts or turns during conversations (as opposed to looking directly at the person he/she is speaking to)

Head tilts or turns during reading or writing (as opposed to looking directly at the task)

Moves in closer to book when reading or writing (for children under 13 years the normal working distance is from the tip of the fist to the elbow, and for age 13+ the normal working distance is between 14-17 inches)

Grips pencil or pen tightly

Wobbly, off balance, or unsteady walking

Toe walker

Figure-ground issues indicating inadequate vision development

Sees the bigger picture but has difficulty recognizing their interrelationships

Overwhelmed with details

Often confused

Avoids dealing with details

Problems with visual memory and/or visualization

Poor spelling

Poor written expression, i.e. using various cognitive operations to translate ideas and thoughts into writing

Poor memory

Poor anticipation/thinking ahead skills

Difficulty applying concepts

C) Medical History

Most recent medical examination (please include doctors name and exam date) *

Results from medical examination: *

Medication(s) currently being taken and for what conditions: *

Your child’s current diet is nutritionally: *

Excellent

Good

Fair

Poor

Child's activity level: *

Extremely

Moderately

Low

Does your child experience periods of very high or very low energy? *

Yes, periods of very high energy

Yes, periods of very low energy

Yes, my child experiences periods of both very high and low energy

No, my child does not experience either periods of high or low energy

Other:

If you choose other, please elaborate

Is your child active? *

Extremely

Moderately

Not

Has your child recently suffered from:

Infection

Injury

Anoxia

Stroke

High fever

Eyestrain

Transient blurred vision

Vertigo

Motion sickness

Does your child experience any of these symptoms:

General fatigue

Loss of visual stamina, i.e. fatigue easily with reading tasks

Loss of speed visual processing, i.e.reading tasks take more time

Reduced peripheral vision

Eyestrain

Headache (especially upon awakening)

Transient blur, i.e. short last blur that occurs often

N/A

Please elaborate on any of the above checked boxes

Does he/she suffer from any chronic illness (asthma, allergies, lupus) or chronic health problems due to glandular, metabolic or organic imbalances, toxic conditions or past traumatic events? If so, please list. *

Has a neurological examination ever been performed? *

Yes

If you answered yes to the above question, who performed the exam, and what were the results of the exam?

Has a psychological examination ever been performed? *

Yes

If you answered yes to the above question, who performed the exam, and what were the results of the exam?

Was the child carried to term? *

Yes

Were there any complications before, after or immediately following the pregnancy or the birth? *

Yes

If you answered yes to the above question, please elaborate:

Did your child crawl (stomach on floor)? *

Yes

At what age did your child crawl? *

Did your child creep (stomach off floor)? *

Yes

At what age did your child creep?

If you answered no to either the question regarding creeping or crawling, please explain:

At what age did your child walk? *

At what age did your child speak their first words? *

Was their early speech clear to others? *

Yes

Is their speech clear now? *

Yes

Any family history of:

High blood pressure

Glaucoma

Diabetes

Learning problems in the mother’s family

Learning problems in the father's family

Psychological disturbance in mother’s family

Psychological disturbance in father's family

If you answered yes to any of the above questions, please indicate who the history pertains to:

D) Present situation

Is there any evidence from the school or psychological tests that some visual malfunction may be present? *

Yes

If you answered yes to the above question, please elaborate:

Please check all that applies to your child: *

Blurred vision

Eyes “hurt” or “tired”

Eyes frequently reddened

Frequent eye rubbing

Frequent blinking

Closing or covering one eye

Head close to paper when reading or writing

Moves head when reading

Skips, rereads or omits words

Reads slowly

Vocalizes when reading silently

Tires easily

Avoids near tasks, i.e. reading, writing, cooking

Short attention span

Poor motor coordination

Grits jaw

Inward turning feet

If you answered yes to any of the above questions, please indicate when this occurs:

List any other complaints your child makes concerning his/her vision:

E) Avocations

Describe what activities compromises the majority of your child's spare time: *

Do they watch TV? *

Yes

If yes, about how many hours per day:

What is their average viewing distance from the TV?

Is your child seriously involved in athletics? *

Yes

Do you feel your child is achieving their potential?: *

Yes

Of all the sports your child has played, list the sports they have excelled in and the sports they have done poorly in:

F) School

At what age did you child start attending school? *

Does your child like school/their teachers? *

Yes

Is your child's schools work: *

Above average

Average

Below average

Does your child like to read? *

Yes

Does your child read voluntarily? *

Yes

If you answered yes to the above question, what do they like to read?

Specifically describe any school difficulties: *

Has your child repeated a grade? *

Yes

If yes, which grade?

Has your child changed schools often? *

Yes

If yes, when?

Does your child seem to be under tension or extreme pressure when doing school work? *

Yes

Maybe

Has your child had any special tutoring and/or remedial assistance? *

Yes

If yes, when, where and from whom?

How well developed is your child’s spoken vocabulary? *

Underdeveloped for their age

Very well developed for their age

G) General Behavior

Any behavioral problems? *

Yes

If yes, please describe (and specify in what setting these behavioral problems occur):

Child's attitude towards reading:

Poor

Excellent

Child's attitude towards school:

Poor

Excellent

Child's attitude towards teachers:

Poor

Excellent

Child's attitude towards parents:

Poor

Excellent

Child's attitude towards siblings:

Poor

Excellent

Child's attitude towards class/playmates:

Poor

Excellent

Yes

Does your child bite their nails? *

Yes

Does your child say and/or do things impulsively?

Yes

Is your child constantly moving? *

Yes

Can your child sit still for long periods of time? *

Yes

H) Please give a brief description of your child

Describe below: *

6-18 Years

6-18 Years INTAKE FORM QUESTIONAIRE.

A) General information

B) Signs of Vision Dysfunction

C) Medical History

D) Present situation

E) Avocations

F) School

G) General Behavior

H) Please give a brief description of your child

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1325 W. Howard Street Evanston Illinois 60202

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