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Primary School

QUESTIONNAIRE FOR PRIMARY SCHOOL CHILDREN

We ask you to take a few moments to complete this form.  The purpose of collecting this information is to assist us in providing your child with the highest quality eye-care.  All information will be treated in the strictest confidence in accordance with the Privacy Act. As you complete this history questionnaire we hope that you will recognize the thoroughness with which your child’s vision will be considered. The examination will take up enough time to permit a very complete investigation. It is desirable to have both parents present during the examination when possible.

Child's Name(Required)
Date of Birth(Required)
Home Address(Required)
Parent/Carer
Please tick here to give us permission to contact Medicare if we need to clarify information regarding item numbers
One of our consultation rooms is upstairs, can you manage stairs?

A. Entering Complaint / Major Concern:

B. Visual History:

Previous Treatment/s(tick all relevant):
Are there any family members with visual difficulties?
Learning Difficulties

C. Development History

Was pregnancy and birth free from complications?
Was pregnancy full term?

D. Were the following developmental areas as expected?:

Crawling on all fours
Walking
Talking
Hearing
Preferred Hand

E. General Health Behaviour

Has your child ever suffered a concussion or head trauma?
Are any medications currently being taken?
Please select any condition that applies

F. Educational Progress

Has your child's school progress been as expected for ability?
Does your child like school?
Does your child like to read?
Does your child read voluntarily?
Has there been any remedial assistance?

1. Please bring any additional information, such as reports from other professionals, that will help us better understand your child.

2. Please bring any spectacles that have been prescribed for your child to the consultation.

PERFORMANCE CHECKLIST

From questioning and observation of your child while he/she is doing VISUAL tasks, are any of the following behaviours or symptoms present. Record your observations as follows:

N Behaviour NEVER observed

S Behaviour SOMETIMES observed.

U Behaviour USUALLY observed.

VISUAL FUNCTION

A. Signs of possible EYE FOCUS problems

Child complains of blurred vision
Difficulty shifting focus repeatedly from far to near
Complains of eyestrain, hurt, or burn after a time on task
Complaints of headaches
Excessive rubbing of eyes
Inattentive to visual detail
Poor reading comprehension & worse after time at task
Tired at end of day
Holds book very close when reading/ writing
Excessive blinking during visual tasks
Demonstrates focus difficulty by squinting, peering etc
Avoids concentrated visual demands

B. Signs of possible EYE TRACKING problems

Loses place often
Skips or re-reads words, letters or lines
Must use finger or guide to keep place
Poor reading comprehension
Short attention span
Moves head excessively when reading

C. Signs of possible EYE TEAMING problems

Covers or closes one eye when reading
Rubs eyes
Complains of eyestrain
Complains of headaches
One eye turns in or out
Complains of double vision
Complains of words moving, dancing or jumbling on page
Inattentive
Reading comprehension reduces after a time on task
Clumsy and poor ball skills
Unusual head turn or body posture when reading or writing

VISUAL INFORMATION PROCESSING:

1. Signs of possible VISUAL - SPATIAL dysfunction

Poor athletic ability
Difficulty with rhythmic activities
Lack of coordination and balance
Clumsy, falls, and bumps into things often
Tendency to work with one side of the body while the other side doesn't participate
Difficulty knowing left and right hand
Reverses letters and numbers when writing or copying
Writes right to left

2. Signs of possible VISUAL ANALYSIS dysfunction

Has trouble learning the alphabet, recognising words, and learning basic mathematical concepts of size, magnitude and position
Confuses likeness and minor differences
Mistakes words with similar beginnings
Difficulty recognising the same word repeated on a page
Difficulty recognising letters or simple forms
Difficulty distinguishing the main idea from insignificant detail
Over-generalises when classifying objects
Has trouble writing and remembering letters and numbers

3. Signs of possible VISUAL - MOTOR integration dysfunction

Difficulty copying from the board
Sloppy drawing or writing skills
Poor spacing and inability to stay on lines
Erases excessively
Can respond orally but not produce answers in writing
Seems to know the material but does poorly on tests
Difficulty writing numbers in columns for mathematical problems
Difficulty completing written assignments in allocated period of time

4. Signs of possible VISUAL - AUDITORY integration dysfunction

Slow learning to match colours to colour names
Slow learning to match shapes to shape names
Slow learning to match letters and numbers to names
Poor spelling ability
Difficulty learning to read phonetically
Difficulty relating symbols to their relevant sounds