Children’s Strabismus Questionnaire Please fill out this questionnaire carefully. Please return it to our office prior to your appointmentPatient’s Name:(Required) First Last GENERAL INFORMATIONWere you referred to our office? Yes No whom may we thank for this referral? Phonehow did you hear about us? Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Child’s Full Name: First Last Birth Date:(Required) MM slash DD slash YYYY Name of school: Address Street Address Address Line 2 City State / Province / Region Grade: Teacher's name First Last School Nurse: First Last Principal: First Last Is your child especially afraid of doctors?(Required) Please list the names and birth dates of your family:Father/Caretaker(Required) First Last Birth Date MM slash DD slash YYYY Mother/Caretaker(Required) First Last Date MM slash DD slash YYYY Sibling First Last Date MM slash DD slash YYYY Sibling First Last Date MM slash DD slash YYYY Sibling First Last Date MM slash DD slash YYYY Sibling First Last Date MM slash DD slash YYYY RESPONSIBLE PERSON INFORMATIONHome Address Street Address Address Line 2 City ZIP / Postal Code Home Phon:(Required)Cell Phone:Father / Caretaker’s Occupation: Business Phone:Business Address: Street Address Address Line 2 City ZIP / Postal Code Mother / Caretaker’s Occupation: Business Phone:Business Address: Street Address Address Line 2 City ZIP / Postal Code MEDICAL HISTORYPediatrician’s Name: First Last Date of Last Evaluation: MM slash DD slash YYYY For what reason? Results and recommendations: Child’s current state of health: Medications currently using, including vitamins and supplements: Is there any history of the following? (please check if there is a history)Diabetes Patient Family Who Blindness Patient Family Who Chromosomal Imbalance Patient Family Who Glaucoma Patient Family Who Multiple Sclerosis Patient Family Who Brain Tumor Patient Family Who High Blood Pressure Patient Family Who Thyroid Condition Patient Family Who Cataracts Patient Family Who Amblyopia(Lazy Eye) Patient Family Who Any history in your family of an eye turn resulting from a disease or other condition? Yes No Other health problems? Yes No please explain: Was there any related trauma, disease, or condition that preceded or accompanied the onset of the eye turn? Yes No please explain: Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes No please list: List illnesses, bad falls, high fevers, etc.:AgeSevereMildComplications Add RemoveHas a neurological evaluation been performed? Yes No By whom? Results: Has a psychological evaluation been performed? Yes No By whom? Results: Has an occupational therapy evaluation been performed? Yes No By whom? Results: DEVELOPMENTAL HISTORYFull-term pregnancy? Yes No Did the mother experience any problems during the pregnancy? Yes No explain: Normal birth? Yes No Were forceps used? Yes No Any complications before, during or immediately following delivery? Yes No Did your child crawl (stomach on floor)? Yes No At what age? Did your child creep (stomach off floor)? Yes No At what age? At what age did your child sit up (without support)? At what age did your child walk (without support)? First words: At what age? At what age did your child speak in a simple sentence (string two words together)? Was your child alert as an infant? Yes No Were there ever any concerns regarding growth or development? Yes No explain: Child’s dominant hand (circle): Right Left Has guidance been given in use of hand? Yes No NUTRITIONAL INFORMATIONCurrent Diet: Excellent Good Fair Poor Are there any indications that you have been exposed to any toxic substances or fumes? Yes No explain: Does your child: Like sweets or crave sweets Yes No what types? Are there any food allergies/sensitivities? Yes No explain: Is your child active? Yes No VISUAL HISTORYAt what age was it first noticed or suspected that was an eye turning? Which eye? Right Left Did the eye begin turning suddenly or gradually? Does the eye turn (check all that apply) In out up down Is the eye turn getting worse or better or is there no change Is it always the same eye that turns? Yes No Is the eye turn always present? Yes No under what conditions is it present? Does the eye always turn the same amount? Yes No explain: Do you notice if the eye turns more when your child is lookingup close? Yes No in the distance? Yes No to your left? Yes No to your right? Yes No up? Yes No down? Yes No Does one pupil ever appear to be larger than the other? Yes No Do you ever notice one or both eyes shaking rapidly? Yes No Does your child report any of the following:Headaches Yes No When: Blurred vision Yes No When: Double vision Yes No When: Eyes tired Yes No When: Eyes hurt Yes No When: Motion sickness / car sickness Yes No When: Redness of the eyes Yes No When: List any other complaints your child makes concerning his/her vision:Do you feel your child’s vision hinders his/her daily activities in any way? Yes No how? Have you or anyone else ever noticed the following:Eyes frequently reddened Yes No when Frequent eye rubbing Yes No When Frequent sties Yes No When Frowning Yes No When Bothered by light Yes No When Closes or covers an eye Yes No When: Difficulty seeing distant objects Yes No When Head close to paper when writing Yes No When Avoids/dislikes reading or other near tasks Yes No When Tilts head when reading or writing Yes No When Moves head when reading Yes No When Confusion of letters or words Yes No When: Reverses letters or words Yes No When Confuses right or left Yes No When Skipping or omitting words Yes No When: Loss of place when reading Yes No When: Need to use finger to keep place Yes No When: Poor reading comprehension Yes No When: Comprehension decreases over time Yes No When: Write or print poorly Yes No When: Difficulty copying form the chalkboard Yes No When Tires easily Yes No When Difficulty with short term memory Yes No When: Difficulty with long term memory Yes No When: Short attention span / loss of interest Yes No When: Poor / awkward fine motor coordination Yes No When: Poor / awkward large motor coordination Yes No When: Dislikes/avoids sports Yes No When: Difficulty hitting / catching a ball Yes No When: PREVIOUS TREATMENTSHas your child had a previous visual evaluation? Yes No Doctor’s Name: First Last Date of last evaluation: MM slash DD slash YYYY Results and recommendations: Were glasses, contact lenses, or other optical devices recommended or prescribed? Yes No bifocal? single vision? contact lenses? Other? Explain: Are they used? Yes No When Why Not Does the eye turn less when the prescription is worn? Yes No Unsure Has there been any treatment using an eye patch? Yes No please describe when the patching was started, how the patching was done, including the age it started, the eye patched, the duration of treatment, and an estimate of the results: Have you ever been told that your child has amblyopia (“lazy eye”)? Yes No Has there been any surgical treatment? Yes No please describe the surgery, including the age surgery was performed, the number of operations, the eye operated on, and an estimate of the cosmetic and subjective results: Were you satisfied with the results of surgery? Yes No Explain: Was the surgeon satisfied with the results of surgery? Yes No Explain: Are you here for a second opinion regarding surgery or further treatment? Yes No Has there been any vision therapy? Yes No Doctor’s name: First Last Please describe the type of vision therapy, including duration, the age at which it started and an estimate of results: FAMILY AND HOMEPlease indicate which adult(s) he/she lives with? Mother Father Stepmother Stepfather Foster Parents Adoptive Parents Grandmother Grandfather Aunt Uncle Other Caretaker please specify: Does your child spend time with any other person, not in the home? Yes No Please explain: Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)? Yes No at what age: Does your child seem to have adjusted? Yes No Was counseling / therapy undertaken? Yes No is it on-going? .. Yes No Is family life stable at this time? . Yes No please explain: Please give a brief description of your child as a person:Is there any other information that would be important / useful in our treatment of your child?RELEASE OF INFORMATION AND INSURANCE FILINGIt is often beneficial to us to discuss examination results and to exchange information with your child’s school, pediatrician, and/or other professionals involved in his/her care. Please sign below to authorize this exchange of information. I agree to permit information from, or copies of, my child’s examination records to be forwarded to other health care providers or insurance carriers upon their written request or upon the recommendation of the ADVANCED EYE CENTER when it is necessary for the treatment of my child’s visual condition, or for the processing of insurance claims. I authorize Dr. Jong and the ADVANCED EYE CENTER to exchange information with my child’s school and other professionals involved in my child’s care by means of my signature below. This authorization shall be considered valid throughout the duration of treatment. Parent’s or Guardian’s SignatureDate MM slash DD slash YYYY I hereby give my permission to the ADVANCED EYE CENTER to treat: Parent’s or Guardian’s SignatureDate MM slash DD slash YYYY Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us to perform a more comprehensive evaluation of your child and to better meet your child’s specific visual needs If you have any questions or concerns that we may answer prior to your appointment, please do not hesitate to contact us. You may leave a message with our answering service 24 hours a day / 7 days a week. We request a minimum of 24 hours notice if you are unable to keep this appointment. Please be on time for your examination so that we will have the maximum opportunity to evaluate your child’s visual status.Please do not bring any other children with you because your undivided attention is necessary during the evaluation.THANK YOU. Sincerely, Susan Jong, O.D Clinical DirectorCAPTCHA