Children’s Strabismus Questionnaire

Please fill out this questionnaire carefully. Please return it to our office prior to your appointment

Patient’s Name:(Required)

First Last

GENERAL INFORMATION

Were you referred to our office?

Yes

whom may we thank for this referral?

Phone

how did you hear about us?

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child’s Full Name:

First Last

Birth Date:(Required)

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

Mother/Caretaker(Required)

First Last

Date

Sibling

First Last

Date

Sibling

First Last

Date

Sibling

First Last

Date

Sibling

First Last

Date

RESPONSIBLE PERSON INFORMATION

Home 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 HISTORY

Pediatrician’s Name:

First Last

Date of Last Evaluation:

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

DEVELOPMENTAL HISTORY

Full-term pregnancy?

Yes

Did the mother experience any problems during the pregnancy?

Yes

explain:

Normal birth?

Yes

Were forceps used?

Yes

Any complications before, during or immediately following delivery?

Yes

Did your child crawl (stomach on floor)?

Yes

At what age?

Did your child creep (stomach off floor)?

Yes

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

Were there ever any concerns regarding growth or development?

Yes

explain:

Child’s dominant hand (circle):

Right

Left

Has guidance been given in use of hand?

Yes

NUTRITIONAL INFORMATION

Current Diet:

Excellent

Good

Fair

Poor

Are there any indications that you have been exposed to any toxic substances or fumes?

Yes

explain:

Does your child: Like sweets or crave sweets

Yes

what types?

Are there any food allergies/sensitivities?

Yes

explain:

Is your child active?

Yes

VISUAL HISTORY

At 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)

out

down

Is the eye turn getting

worse

or better

or is there no change

Is it always the same eye that turns?

Yes

Is the eye turn always present?

Yes

under what conditions is it present?

Does the eye always turn the same amount?

Yes

explain:

Do you notice if the eye turns more when your child is looking

up close?

Yes

in the distance?

Yes

to your left?

Yes

to your right?

Yes

up?

Yes

down?

Yes

Does one pupil ever appear to be larger than the other?

Yes

Do you ever notice one or both eyes shaking rapidly?

Yes

Does your child report any of the following:

Headaches

Yes

When:

Blurred vision

Yes

When:

Double vision

Yes

When:

Eyes tired

Yes

When:

Eyes hurt

Yes

When:

Motion sickness / car sickness

Yes

When:

Redness of the eyes

Yes

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

how?

Have you or anyone else ever noticed the following:

Eyes frequently reddened

Yes

when

Frequent eye rubbing

Yes

When

Frequent sties

Yes

When

Frowning

Yes

When

Bothered by light

Yes

When

Closes or covers an eye

Yes

When:

Difficulty seeing distant objects

Yes

When

Head close to paper when writing

Yes

When

Avoids/dislikes reading or other near tasks

Yes

When

Tilts head when reading or writing

Yes

When

Moves head when reading

Yes

When

Confusion of letters or words

Yes

When:

Reverses letters or words

Yes

When

Confuses right or left

Yes

When

Skipping or omitting words

Yes

When:

Loss of place when reading

Yes

When:

Need to use finger to keep place

Yes

When:

Poor reading comprehension

Yes

When:

Comprehension decreases over time

Yes

When:

Write or print poorly

Yes

When:

Difficulty copying form the chalkboard

Yes

When

Tires easily

Yes

When

Difficulty with short term memory

Yes

When:

Difficulty with long term memory

Yes

When:

Short attention span / loss of interest

Yes

When:

Poor / awkward fine motor coordination

Yes

When:

Poor / awkward large motor coordination

Yes

When:

Dislikes/avoids sports

Yes

When:

Difficulty hitting / catching a ball

Yes

When:

PREVIOUS TREATMENTS

Has your child had a previous visual evaluation?

Yes

Doctor’s Name:

First Last

Date of last evaluation:

Results and recommendations:

Were glasses, contact lenses, or other optical devices recommended or prescribed?

Yes

bifocal?

single vision?

contact lenses?

Other?

Explain:

Are they used?

Yes

When

Why Not

Does the eye turn less when the prescription is worn?

Yes

Unsure

Has there been any treatment using an eye patch?

Yes

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

Has there been any surgical treatment?

Yes

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

Explain:

Was the surgeon satisfied with the results of surgery?

Yes

Explain:

Are you here for a second opinion regarding surgery or further treatment?

Yes

Has there been any vision therapy?

Yes

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 HOME

Please indicate which adult(s) he/she lives with?

please specify:

Does your child spend time with any other person, not in the home?

Yes

Please explain:

Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)?

Yes

at what age:

Does your child seem to have adjusted?

Yes

Was counseling / therapy undertaken?

Yes

is it on-going? ..

Yes

Is family life stable at this time? .

Yes

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 FILING

It 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 Signature

Date

I hereby give my permission to the ADVANCED EYE CENTER to treat:

Parent’s or Guardian’s Signature

Date

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 Director

CAPTCHA

GENERAL INFORMATION

RESPONSIBLE PERSON INFORMATION

MEDICAL HISTORY

DEVELOPMENTAL HISTORY

NUTRITIONAL INFORMATION

VISUAL HISTORY

PREVIOUS TREATMENTS

FAMILY AND HOME

RELEASE OF INFORMATION AND INSURANCE FILING

Advanced Eye Center