Teacher Questionnaire To the teacher of: SelectMr.Mrs.Ms.MissMasterMxDr. Title First Name Last Name Pro NounsSelectHe/HimShe/HerThey/ThemYear School The student named above is receiving vision care at our clinic. In order to address the impact of vision problems on classroom performance, we would appreciate your observations of this child’s behaviour in school. It has been shown that the teacher is frequently the best observer for identifying vision problems that tend to interfere with school work. The following checklist identifies many of the observable clues and symptoms that are often observed in a child with a vision problem. Please read through this list and check items that you have noted to occur frequently in this student’s case.Appearance of Eyes Reddened eyes or lids Excessive tearing of eyes, or rubs eyes Blinks excessively Refractive Error or Eye Focusing (Accomodation) Problem Blinks eyes excessively during near tasks Frowns, scowls, or squints to see whiteboard Avoids close work Fatigues easily during visual tasks Rubs eyes during or after visual activity Complains of blur while reading or writing Comprehension is poor when reading or performing near tasks Eye Tracking (Ocular Motility) Problem Skips or rereads words or letters Rereads lines or phrases Mistakes words with similar beginnings or endings Uses finger or marker when reading Loses place often when reading Repeatedly omits “small” words Moves head excessively as reads across page Eye Teaming (Binocularity) Problem Complains of seeing double Covers or closes one eye One eye turns (in, out, up, or down) at any time Tilts or turns head to one side Squints, closes, or covers one eye Complains of letters or lines “floating,” “running together,” or “jumping around” Reports confusion of what is seen Visual Information-Processing Problem Confuses similar words Fails to recognize same word in next sentence or page Confuses minor likenesses and differences Makes errors in copying from board or book Difficulty following verbal instructions Difficulty completing assignments in time allotted Poor printing or handwriting Short attention span, distractible Says words aloud or moves lips as reads Reverses letters, numbers, or words Poor ability to remember what is read Poor eye-hand coordination Repeatedly confuses right-left directions Poor recall of visually-presented tasks School performance not up to potential Please comment on the following:Does this child have any academic problems? Yes No If so, please explain (e.g., subject material, behavior, etc.) Is (s)he in the top third, middle third, or lower third of his/her class? How does academic achievement compare with potentialAt what grade level does this child read Please check any areas of difficulty: Vocabulary Reading Attention Math Skills Word recognition Interpretation Comprehension Spelling Oral reading Silent reading Memory Written work Do you feel that there are any factors that may be interfering with academic achievement?Any other observations and/or comments which you feel may be beneficial to us would be appreciated.May we contact you if further information is required? If so, please provide a telephone number at which you can be reached and the best time to call.Teacher's name SelectMr.Mrs.MissMasterMxDr. Title First Last Pro NounsSelectHe/HimShe/HerThey/ThemPhoneBest time to call: School Name School AddressTeacher SignatureCAPTCHA
