Children's Health Questionnaire

Children's Health Questionnaire
General Information
Appointment Date:
MonthDayYear
Date
Hour MinutesAM/PM Option
Child's Name:
First Name Last Name
Nickname:
Gender
MaleFemaleNon-BinaryPrefer not to say
Home Address:
Street Address
Street Address Line 2
CityProvince
Postal Code
Home Phone Number:
Cell Phone number
Child's Birthdate:
MonthDayYear
Date
Grade:
Age:
Child's Dominant Hand:
RightLeftAmbidextrous
Is Your Child:
Well coordinatedCoordinatedClumsy/ Poorly coordinated
Is your child especially afraid of Doctors?
YesNo
How did you hear about our office?
Word of Mouth, Website, Google, Newspaper
Were you referred to our office?
YesNo
If Yes, whom should we thank for the referral?
First NameLast Name
Name of School:
Teacher's Name:
First NameLast Name
Principal:
Please list the name and ages of your family members
Name Age
Father/Caregiver
Mother/Caregiver
Sibling
Sibling
Sibling
Father/Caregiver's Occupation:
Cell Phone Number:
Email:
example@example.com
Mother/Caregiver's Occupation:
Cell Phone Number:
Email:
example@example.com
Responsible Person Information
Person Responsible for Patient's Account:
First NameLast Name
Relationship to Patient:
Home Address (if different from patient's):
Street Address
Street Address Line 2
CityProvince
Postal Code
Home Phone Number (if different from patient's):
Cell Phone Number:
Medical History
Paediatrician Name:
Date of last exam:
MonthDayYear
Date
Child's current state of health:
Would you like us to send a report of today's findings to your child's Paediatrician?
YesNo
Medications currently taking, including vitamins and supplements:
Medication Condition
1.
2.
3.
4.
Is your child allergic to any foods or medications?
Please list any serious illnesses, bad falls, fevers, etc. :
Any reactions to immunization(s):
YesNo
Please explain:
Is family history unknown?
Yes, it is unknown.No, it is known.

Is there any history of the following for your child or a family member:

	Child	Family Member
Allergies	1	2
Concussions	3	4
ADD/ADHD	5	6
Chronic Ear Infections	7	8
Asthma	9	10
Autism Spectrum	11	12
Diabetes	13	14
Amplyopia (Lazy Eye)	15	16
Strabismus (wandering eye)	17	18
High Blood Pressure	19	20
Glaucoma	21	22
Age-Related Macular Degeneration (ARMD)	23	24

Has your child seen a neurologist?
YesNo
Has your child seen a psychologist?
YesNo
Has an occupational/speech/physical therapy evaluation been performed?
YesNo
Nutritional Information
Current diet:
ExcellentGoodFair
Is your child active:
YesNo
How active:
LittleModeratelyExtremely
Are there periods of:
Very high energyVery low energy
Please explain:
Developmental History
Full term pregnancy:
YesNo
How many weeks:
Mother's age when born:
Under 2021-3031-40Over 40
Did the mother experience any health problems during pregnancy?
YesNo
Please explain:
Natural birth:
YesNo
Length of labour:
Hours
Induced:
YesNo
Were forceps used ?
YesNo
Cesarian birth:
YesNo
Was the delivery:
ScheduledEmergency
Any complications before, during, or immediately following delivery?
YesNo
Please explain:
Birth weight:
Apgar score:
At birth
Apgar score:
After 10 minutes
Was there ever any reason or concern over your child's general growth or development?
YesNo
If yes, why?
Please indicate at what age your child reached the following milestones:
Sitting:
Crawling:
Walking:
First spoke at what age:
Age
First words:
ball, mama, etc
At what age did your child use short sentences?
Was speech clear to others:
YesNo
Is speech clear now:
YesNO
Can your child ride a bike?
YesNo
How old were they when they learned to ride a bike without training wheels?

Type a question
I hereby give permission to Doctors Vision Centre Vision Therapy to disclose any information related to my child's visual and medical condition(s) with the following family member(s) and/or caregiver(s):No thank you
Name:
First NameLast Name
Phone:
Name:
First NameLast Name
Phone:
Name:
First NameLast Name
Phone:
Name:
First NameLast Name
Phone:
How should we contact you?:
Home phoneCell phoneEmail
If you provide your email address, we may contact you via email to send reports, and general correspondence. Emails are sent from our secure system; we will not send health information if you request us not to do so.
The information provided on this questionnaire is current and correct to the best of my knowledge, and I hereby give my permission to the doctors and therapists at Doctors Vision Centres Vision Therapy to treat my child.
Signature
Clear
Name of Person signing
First NameLast Name
Date
MonthDayYear
Date
Relationship to patient:
Should be Empty:

	Never	Seldom	Occassionally	Frequently	Always
Headaches
Blurred vision
Double vision
Eyes hurt
Eyes tired
Words move on the page
Motion sick/car sick
Does their head hurt when they learn?

	Never	Rarely	Frequently	Always
Reddened eyes or lids
Eye rubbing or watering
Squinting or frowning
Frequent blinking
Bothered by light/light sensitive
Closing or covering one eye

	Never	Rarely	Frequently	Always
Difficulty seeing distant objects
Head is close to the page when reading or writing
Avoids reading/prefers to be read to
Tilts or turns head when reading or watching TV
Tires easily during visual tasks
Frowns, squints or scowls to see whiteboard
Rubs eyes during or after visual activity
Complains of blur while reading or writing
Poor reading comprehension
Short attention span/loses attention easily
Fluctuating vision at near
Blurriness when copying from the board

	Never	Rarely	Frequently	Always
Moves head when reading
Skips or rereads words or letters
Rereads lines or phrases
Mistakes words with similar beginnings or endings
Uses finger or ruler when reading
Loses place while reading
Omits "small" words while reading
Vocalizes while reading silently
Reads slowly or choppy
Reads without expression
Poor reading comprehension
Difficulty or slow copying from the whiteboard

	Never	Rarely	Frequently	Always
Sees Double
Covers or Closes an Eye
One eye turns in/out/up/down at any time
Tilts or turns head to one side
Complains of letters or lines "floating"
Words run togethor or jump around on the page
Difficulty catching or hitting a ball
Difficulty aligning columns of numbers

Children's Health Questionnaire

General Information

Responsible Person Information

Medical History

Nutritional Information

Developmental History

Present Situation

Visual History

Have you, or anyone else ever noticed the following in your child:

Television Viewing / Leisure Activities

School

General Behaviour

Family and Home

	Never	Rarely	Frequently	Always
Confuses or forgets letters, number, or words
Reverses letters, number, or words
Confuses left and right
Writes crooked, poorly spaced or poorly sized
Does not support paper when writing
Awkward or immature pencil grip
Frequent erasing
Difficulty remembering same word on different page
Difficulty with memory
Remembers better what is heard, than written
Seems to know material, but does poorly on tests
Poor gross motor coordination
Poor fine motor coordination
Difficulty following directions
Fails, or takes a long time, to complete tasks
Overly shy
Sensitive to texture; food or clothing
Sensitive to sounds
Anxiety with reading or school tasks
Meltdowns
Confuses directions
Doesn't recognize the same word in the next sentence
Mistakes words with similar beginnings or endings
Difficulty learning to recognize the alphabet
Ignores details of Visual tasks
Moves lips or whispers to self when reading silently
Poor spelling
Difficulty with Math concepts
Difficulty visualized what is read
Sloppy writing and drawing skills
Writes crookedly and has poorly spaced letters and words

	Name	Age
Father/Caregiver
Mother/Caregiver
Sibling
Sibling
Sibling

	Medication	Condition
1.
2.
3.
4.