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Holistic Developmental Behavioral Optometrist

Burke Professional Center

9002 Fern Park Drive

Burke. VA 22015

Phone: 703-978-5010

Fax: 703-978-5011

 

 
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Dr. Alan Sikes Optometry

Holistic Vision Care

 

Please find the Developmental History Questionnaire below. To download a printable copy in Microsoft Word Format, Please Click Here.

 

 

DEVELOPMENTAL HISTORY QUESTIONNAIRE

TO THE PARENTS OF:                                                                                                                               
ADDRESS:                                                                                                                                                   

 

This history questionnaire is sent to you for completion and serves several purposes. It will allow you to refer to baby books and other records for more accurate answers. It gives us more time to spend with your child while in the office for actual examination because this part of the case record is thus completed in advance. It allows us to plan in advance for the tests and examination routines which will best apply to your child’s problems.

You might wonder, since this is a visual examination, why some of these questions are asked. Two questions in the Developmental History section are a good example for explanation. Ages at time of walking and talking are requested. The nervous system that controls walking also controls eye movements. The other nervous system controlling actions like talking also controls focusing of eyes. Thus we can determine early visual behaviors by comparison to walking and talking development. In a number of cases of strabismus and amblyopia, the person walked early, or late, and/or missed doing enough crawling to help establish good two eye teaming. Therefore it is very important that you fill in every blank that applies to your child, as best you can.

CHILD’S FULL NAME                                                                                DATE                                    
BIRTHDATE                                     AGE NOW                             NICK NAME                                    
PARENT’S NAME                                                                OCCUPATION                                             
ADDRESS                                                                                                     PHONE                                 
NAME OF SCHOOL                                                                                                GRADE                                 
ADDRESS                                                                                                                                                    
TEACHER’S NAME                                                                           

  1. PRESENT SITUATION:
    1. Why do you think your child needs a visual examination?                                                                                                                                                                                                                           
    2. Have you noted any difference in this child compared to other children (brothers, sisters, or playmates)?                                                                                                                                                                                                                                                                                                
    3. Who first noted the visual difficulties? When?                                                                                                                                                                                                                                             
    4. Did this difficulty occur suddenly?                                                                                                                                                                                                                                                               
    5. Did it seem related to illness, accident or any other related occurrence?                                                                                                                                                                                                      
    6. Was attention recommended by school teacher or school nurse?                                                      

      Why?                                                                                                                                                  

7. Have you noticed anything in home behavior or suggest possible difficulties?                      
Describe briefly                                                                                                                            

  1. GENERAL HEALTH:

1.   Illness and age at time of each.

  1.                                                                               Age:                Severity:                                 
  2.                                                                               Age:                Severity:                                 
  3.                                                                               Age:                Severity:                                 

COMMENTS:                                                                                                                                                                                                                                                                                                                                                                                                                                                             

  1. Asthma, eczema, or allergies (frequency and treatment)?                                                                                                                                                                                                                             
  2. What drugs (such as penicillin and sulfas) have been given and for what?____________________

      Any reaction? _________________________________If so, describe briefly_________________

  1. Is your child receiving and medication at present?________________ Purpose ________________
  2. Does your child become feverish easily? _______________________ When? _________________

      Is it a high fever? _________________ What and when was the highest fever? ________________

  1. Teeth: Condition? ___________________ Severity and quantity of decays? ___________________
  2. Condition of tonsils? _______________________________________________________________
  3. Injuries or accidents? _______________________________________________________________

      Involving eyes? ________________________________ Involving spine? _____________________
Involving head? Type ___________________________________ When? _____________________

  1. DEVELOPMENTAL HISTORY:

1. Full term pregnancy? ____________________________________ Normal Birth? ______________
Any complications before, during or immediately after delivery? ____________________________
If so, describe briefly ______________________________________________________________
2. At what age did your child crawl? _____________________________________________________
Was it good “all four” crawling? __________ If otherwise, describe briefly ____________________
3. At what age would your child pull himself up to chairs and tables? _______
4. At what age did your child walk? ________
Did (s)he walk well without unusual stumbling or frequent accident, once (s)he learned? __________
5. Was your child very active in the crib, and since? _________________________________________
6. Does your child run a lot? _________ Does his/her running seem aimless? _____________________
7. At what age did your child first make speech sounds? ______________________________________
When, and what were the first words? ___________________________________________________
When were the first phrases? _______________________ Sentences? _________________________
Was speech clear? _________________________________
Could others than family understand your child’s early speech? _________
Is speech clear and adequate now? ________________________________
8. Was your child an “easy” or difficult baby? ________________ “Good” or “Fussy”? _____________
Any colic or early management problems? ___________
9. Can your child dress himself? ________ Button Clothes? _________ Tie Bows? _________________
Zip zippers? __________ Lace Shoes? _________ Could (s)he do these before entering school? _____

  1. GENERAL BEHAVIOR

1. Does your child need a lot of sleep? _______ Does (s)he go to bed early at night? ________________
When did your child stop taking naps? __________ Does (s)he sleep soundly? __________________
What are the usual hours of sleep? From ____ to ____ Does (s)he awaken fresh and rested? ________
2. Have you noted frequent extreme fatigue? ________ When? _________________________________
Does fatigue result in sag, excitability, or irritability? _______________________________________
Is your child’s visual difficulty more noticeable with fatigue? ________________________________
3. Is your child a good eater? ____________ Is intake low, medium or large? ______________________
Is there a variety of good intake? ______________ Is there a high desire for sweets? ______________
4. Have there been any elimination problems? ___________ If so, when? _________________________
5. Is there any tensional behavior such as nail biting, eye blinking, or rubbing (or other than normal with                 sleepiness), tantrums, tongue chewing or extension, etc? _______
If so, when? ___________________________________________
Do any of these tensional behaviors seem related to school, movies, or TV? ____________________
If so, describe briefly _______________________________________________________________
6. What hand does your child prefer to use for eating? ________________________________________
For writing? _____________ For Drawing? ____________ For usual play? ____________________
Which foot is used for kicking? _______________ Was handedness ever changed? ______________
7. What are usual play activities? _________________________________________________________
What activities hold interest the longest? _________________________________________________
What are your child’s special interests? __________________________________________________
Is play very active, or very quiet? _______________________________________________________
Does (s)he stumble or run into things? __________
Does (s)he play easily and well with other children? __________
8. Is your child good with hands (for present age)? ___________ Is block play good? _______________
Do erector sets, puzzles, coloring and cutting hold attention? _________________________________
Are drawings or block arrangements good representations of what your child names them to be? _____
Can (s)he throw and catch a ball?__________________
9. Does your child get along well with adults? _______________________________________________
With other children (same, younger or older)? _____________________________________________
10. Is your child observant? __________ Is your child distractible? ______________________________ 
11. Does (s)he prefer CD, radio or television? ____________
What CD’s or programs hold attention the longest? ________________________________________
12. Does your child like books and magazines? ___________ Does (s)he like to be read to? __________
Does (s)he prefer to hold the book while being read to? ____________
When do you do the most reading to your child—naptime, bedtime, or other? ___________________

  1. SCHOOL

1. Age of entrance in first grade? Yrs ______ Mos. __________
Age of entrance in nursery school? Yrs ______ Mos. __________
Age of entrance in kindergarten? Yrs ______ Mos. __________
If so, length of time spent in nursery school or kindergarten? _____________
2. Does your child like school? _______ Teacher? __________ Other children at school? ____________
Does (she) hate to miss school? ____ Is school attendance regular? _____ Frequent absences? ______
Why? _____________________________________________________________________________
3. How is your child getting along in school?                                                                                         
In your opinion what is the best subject?         Easiest subject?           Hardest subject?                   
If there is difficulty at school, what do you think is the reason?                                                        
Present school difficulties?                    When first noticed?                            By whom?                  
4. What does you child report about school or school work?                                                                       
Has the teacher reported anything about your child’s schoolwork?                                                    
5. Does your child have difficulty copying from chalkboard?                                                                
6. Has your child had any remedial work?                                                                                              
In what?                                                                        From whom?                                                             
7. Has (s)he changed schools or teachers?            Frequency?                  When and why?                    
Has (s)he ever repeated a grade?                      Why?                                                                          

  1. VISUAL HISTORY:
    1. Has there been previous visual care?               When and by whom?                                                

      Were drops used?                              
Were there any reactions or damaging effects from the “drops” that you could observe?               
If so, describe in full                                                                                                                          
Why were glasses prescribed?                                                           
How frequently have your child’s lenses been changed?                                                                  
Were the lenses “stronger” each time?                       
When are the glasses worn?                                                                                       
Does your child wear the glasses without constant suggestion?                   
Have parents, brothers or sisters had visual attention and care?                   

Age of brothers and sisters and why glasses are worn:

  1. Name:                                                        Age:                 Visual situation                                 
  2. Name:                                                         Age:                 Visual situation                                
  3. Name:                                                         Age:                 Visual situation                                
  4. Name:                                                        Age:                 Visual situation                                 
  5. Name:                                                         Age:                Visual situation                                 
    1. Does your family read a lot?                                      
    2. When does this child report: headaches?                     Blurred vision or “stinging”/                     eyes “hurt”

                   or “tired”?                  seeing double?                       Blur at distances (like movie or chalkboard)?                                                                  Blur at a near while reading?                                     

    1. Does (s)he ever close or cover one eye?                                  When?                                   

      Do bright lights bother?                                   When?                                                           
Are eyes frequently bloodshot?                                              When?                                    
Are there frequent styes?                                                          When?                                   
Rubbing of eyes?                                                                     When?                                                Excessive blinking?                                                                When?                                   

5.   Does this child like to read?                           How much does (s)he do?                                         
Does (s)he reverse words or letters in reading and spelling?                                                             
Does (s)he skip words or re-read?                                                                                                     
Does (s)he move lips while reading to himself?                                                                                
Does (s)he movie head while reading?                                                                                              
Does (s)he tilt head while reading?                                                                                                   
Does (s)he frown or squint at reading or TV?                                                                                   
Does (s)he use finger or marker to follow words if permitted?                                                         
Is book held too close while reading?                                                                                                           
Does this child read as well as others in same grade?            Or as brothers and sisters?                 
COMMNETS AND OTHER PERINENT INFORMATION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

PARENT’S SIGNATURE:                                                                                                                     

As you complete this questionnaire you will recognize the thoroughness with which your child’s problems will be considered. So you may plan accordingly, we will allow enough time for this examination to permit a very complete optometric investigation of the problem.
If you desire discussion of any of the above, please check the question number so we can be sure to consider it with you while in the office. We prefer to have both parents present for the examination and the case discussion that follows, but it is not mandatory. We have found that it is difficult for either mother or father to carry home full information about the child to the other parent. When visual care is necessary for a child, the results and progress are much more satisfactory when both parents are fully and completely aware of the problem and its solution. Furthermore, your child’s future deserves the fullest consideration that you as parents and we here in the office, can provide.

Thank you,
Dr. Alan L. Sikes
Developmental Behavioral Optometrist



 


Hours

Mon. - Thurs. 8:30am - 7pm

Friday

8:30am-2:30pm
Saturday 11:30am-1:30pm

We are proud members of the following organizations:

College of Optometrists in Vision Development (C.O.V.D.)

The Optometric Extension Program (OEP) 

American Optometric Association (AOA)

The Northern Virginia Optometric Society (NVOS)



 
 
 
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