Developmental History

Normal birth?

Did your child crawl?

At what age? (crawl)

Age at which child walked?

Age of speech? (first words)

Age of speech? (sentences)

When fatigued, child will:

Under stress, is there any pattern of behavior, thumb-sucking, etc?

What time does your child go to sleep?

What time does your child wake up?

How long is your child on a screen per day?

Is your child adopted?

If yes, does the child know?

Age when adopted

At what age did your child start school?

At what age did your child start school?

How did your child react to retention?

In your opinion, what is the quality of your child’s school work?

Have there been any specific school difficulties?

What subject(s) are considered easiest?

What subject(s) are considered most difficult?

Does test taking appear to cause anxiety?

Does the school consider your child to have a discipline problem?

Does your child like to read (or with you if pre-reading age)?

Has the child experienced a recent trauma to their head?

Has the child suffered a recent illness? (cold/flu/Covid)

How long have you noticed the difficulty in your child?

Date of previous eye examination (not at our office):

Date of previous eye examination (not at our office):

Doctor's Name

Date of Exam

Members of family who have had vision or binocular issues and why:

Relationship to patient

Diagnosis (for example; myopia/strabismus/amblyopia)

Relationship to patient

Diagnosis (for example; myopia/strabismus/amblyopia)