Children Amblyopia & Strabismus Questionnaire

Please fill out this questionnaire carefully. Thank you!
Child’s Name*
First Last
Age
Date of Birth*
MM slash DD slash YYYY
Gender
Primary Phone Number*
Secondary Phone Number
Email*
Whom may we thank for referring you?
Names of Parents or Legal Guardians
Parents or Guardians’ Occupation
Email Address
Main Concerns/Reason for visit
MEDICAL HISTORY
Date of most recent medical exam
Doctor’s name
List any medications*
List any head injuries, illness and any chronic problems*
Any neurological and/or psychological evaluation been performed (please circle)?*
- Yes
- No
Any current or past Occupational, Physical and/or Speech Therapy (please circle)?*
- Yes
- No
Is there any history of the following?
Child Family
Eye Turn(Strabismus)
Lazy Eye(Amblyopia)
High Prescription
Learning Disabilities
Eye Shake(Nystagmus)
ADD/ADHD
Autism
DEVELOPMENTAL HISTORY
Period of Pregnancy(weeks)*
Peri-natal Complications*
Age when child first:
Sit
Sit
Crawl
Crawl
Walk
Walk
Talk
Talk
Is your child performing below, above or at grade level for knowing numbers/letters, writing and reading?*
List any past or current tutoring, Early Childhood Services and/or Individualized Program Planning (IPP)?*
VISUAL HISTORY
Date of last eye exam
Name of optometrist
Date of last dilated eye exam (eye drops to enlarge the pupils)
Age when your child received the first pair of glasses
Age of current glasses
Are they worn full time or part time?
- Yes
- No
For near or distance or both?
- Yes
- No
Are there prisms in your child’s current glasses?
- Yes
- No
Has your child worn prism glasses previously?
- Yes
- No
Have you ever been told your child has a lazy eye?
- Yes
- No
If your child has worn an eye patch
how many hours/day
how many times/week
and for a total of how many months?
What activities were performed while patching?
EYE TURN HISTORY
Is your child seeing an eye surgeon/ophthalmologist? Who?*
Results and recommendations by ophthalmologist?
Has your child had eye muscle surgeries? If yes, when?*
After how long after the last eye surgery did the eye begin turning again?
Which eye is turning?*
Does the eye turn: in, out, up or down?*
At what age did the eye turn start?
Did the eye begin turning suddenly or gradually?
Is the eye turn getting worse or better, no change since initial onset?
What percentage of waking hours does the eye turn?*
Is the eye turn worse when looking (please circle) at ?
- Near
- Distance
Is the eye turn worse when looking (please circle) to the ?
- Right
- Left
- Up
- Down
Does one pupil ever appear to be larger than the other?
- Yes
- No

Please assign a value between 0 and 3 for each symptom*

	0 = symptom not present	1 = symptom minimally present	2 = symptom moderately present	3 = symptom severely present
Bumping into objects/clumsy
Avoidance/poor focus with near work/reading
Headaches around the eyes/forehead
Head turn or tilt when looking at something
Holding reading material too close
Skipping of words when reading
Trouble catching a ball
Slow at copying from the board at school

Additional comments you would like us to know

Children Amblyopia & Strabismus Questionnaire

MEDICAL HISTORY

DEVELOPMENTAL HISTORY

VISUAL HISTORY

EYE TURN HISTORY

Bridgeland (Browz Eyeware)

Panorama Hills (Progressive Optometry)

Douglasdale – South Trail Crossing

Macleod Trail

	Child	Family
Eye Turn(Strabismus)
Lazy Eye(Amblyopia)
High Prescription
Learning Disabilities
Eye Shake(Nystagmus)
ADD/ADHD
Autism