CHILD HISTORY FORM

Does your child complain about:

Headaches

Yes

No

Blurred Vision

Yes

No

Double Vision

Yes

No

Eyes 'hurt' or 'tired'

Yes

No

Have you or anyone else ever notice the following?

Holding reading close

Yes

No

Closing one eye

Yes

No

Covering one eye

Yes

No

Eyes frequently bloodshot

Yes

No

Frequent styes

Yes

No

Excessive eye rubbing

Yes

No

Excessive eye blinking

Yes

No

Losing place while reading

Yes

No

Tilting head while reading

Yes

No

Poor posture while reading

Yes

No

Bumping into objects

Yes

No

Poor general coordination

Yes

No

Bothered by light

Yes

No

Avoiding close work

Yes

No

Fatigue after close work

Yes

No

One eye turning in or out

Yes

No

Squinting

Yes

No

Developmental History:

Full term pregnancy?

Yes

No

Normal birth?

Yes

No

Has handedness ever changed?

Yes

No

School History:

Does your child like school?

Yes

No

Does your child like to read?

Yes

No

Have any grades been repeated?

Yes

No

Any difficulties in school?

Yes

No

Does/has your child received any tutoring?

Yes

No

Has the school reported anything about your child’s schoolwork or concerns about his/her vision?

Has the school reported anything about your child’s schoolwork or concerns about his/her vision?

Yes

No

Health History:

List of past illnesses / current health problems:

History of high fevers?

Yes

No

History of injuries to eye / head?

Yes

No

Visual History:

Dates of previous eye examinations, and type of treatment (glasses, vision therapy, etc.)

Members of immediate family with vision difficulties:

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.