Name: Eye Health Centre
Address: 114-506 St. Albert Trail, St. Albert, AB, T8N 5Z1, CA
Telephone: 780-419-7000
Price range: $000 - $300

Please fill out the questionnaire carefully before your appointment. The time spent answering questions will allow the doctor to better plan the flow of the examination procedures.

Thank you for your time and effort in completing this questionnaire. Leave blank or put N/A besides questions that do not apply.

Step 1 of 8 - PATIENT INFORMATIONS

PATIENT INFORMATIONS
Patient Name
First Last
School
Grade
Teacher
Parent’s Names
First Last
Form Completed by
Who referred you to Eye Health Centre?
Date
MM slash DD slash YYYY

PRESENT SITUATION AND SYMPTOMS
What are the concerns that prompted this functional vision evaluation?
How long have these concerns been observed?
What goals do you hope to accomplish from the functional vision evaluation and/or perceptual vision evaluation?
In your opinion, is vision impacting academic performance?
Has your child expressed concerns regarding vision?

VISUAL HISTORY
Last Eye Exam (year)
Doctor
City
Were glasses, contact lenses or other optical devices prescribed or recommended? If so, what? and do you use them? If not using them, why?
Explain any history of eye surgeries, eye/head injury, vision therapy or other treatments in the past (related or not to current concerns)

LEISURE TIME ACTIVITIES
How much time per day does your child spend watching TV?
Viewing distance?
How much time per day does your child spend on computer/video games?
What extracurricular activities does your child enjoy?
Are there any activities your child would like to participate in, but doesn’t?
- Yes
- No
Please explain

	Yes	No
Did your child crawl (stomach on floor)?
Did your child creep (on all fours)?
At what age did your child start to walk?
Did your child have difficulty learning to throw or catch a ball?
Did your child have difficulty learning to cut with scissors?
Did your child have difficulty learning to tie shoelaces?
Did your child have difficulty learning to ride a bicycle?

Child Questionnaire

Step 1 of 8 - PATIENT INFORMATIONS

PATIENT INFORMATIONS

PRESENT SITUATION AND SYMPTOMS

VISUAL HISTORY

QUALITY OF LIFE CHECKLIST

DEVELOPMENTAL HISTORY

SCHOOL HISTORY

MEDICAL HISTORY

LEISURE TIME ACTIVITIES