Pediatric Forms PRINTABLE PDF PATIENT’S NAME First Last DATE OF BIRTH MM slash DD slash YYYY If this form is completed by a parent/guardian, what is your relationship to the child?PRESENT SITUATION: In what ways do you seem to have difficulty? (How does your child complain about his or her vision?)Has anyone noticed an eye turn in or wander out? Yes No Which eye?When?Do you experience any of the following. If yes, when? Headaches When Blurred Vision Far When Blurred at Near When Eyes Hurt or Tired When Double Vision When Light Sensitivity WhenHave you ever noticed the following? Holding reading close When Holding reading farther away When Distorted posture when reading When Inability to see distance objects When Closing one eye When Covering one eye When Bumping into objects When Poor general coordination When Eyes frequently reddened When Frequent styes When Excessive eye rubbing When Skips words or rereads When Reverses words/letters When Moves lips while reading quietly When Get lost in book/unaware of surroundings When Moves head while reading When Uses finger to follow words When Tilts head while reading When Bothered by light WhenDoes the patient have a speech or language deficit? Yes No If Yes, has any attempt been made to correct it? Yes No By Whom?Was therapy helpful? Yes No Have you ever had any eye surgeries or injuries? Yes No Please ExplainHave you ever had vision therapy? Yes No When?By Whom?Was it helpful? Yes No Does your job/school include using a computer tablet? hours/dayHow do you spend your free time?How many hours a day do youuse a digital devicereadwatch TVAre you involved in sports? Yes No Which one(s)What kind of exercise do you do? Δ
