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Developmental History
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Developmental History
Please fill out to the best of your knowledge. Skip any questions that are not applicable.
Developmental History
Your name
*
Email address
*
Child's name
*
Child's DOB
*
Full term pregnancy (no. of weeks)?
Normal birth?
Yes
No
Was the child exposed in utero to:
drugs
alcohol
nicotine
none
Did your child crawl?
Yes
No
At what age?
Age at which child walked?
Age of speech? (first words)
Age of speech? (sentences)
When fatigued, child will:
Physically droop
Becomes irritable
Becomes excited
Under stress, is there any pattern of behavior, thumb-sucking, etc?
What time does your child go to sleep?
Please select
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00 or after
What time does your child wake up?
Please select
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00 or later
How long is your child on a screen per day?
Please select
30 minutes or less
1 hour
1 1/2 hours
2 hours
2 1/2 hours
3 hours
3 1/2 hours
4 hours
4 1/2 hours
5 hours
5 1/2 hours
6 hours
6 1/2 hours
7 hours
7 1/2 hours
8 hours or more
Is your child adopted?
Yes
No
If yes, does the child know?
Yes
No
Age when adopted
School
At what age did your child start school?
Please select
2
2 1/2
3
3 1/2
4
4 1/2
5
5 1/2
6
6 1/2
7
What grade did they start school at?
Please select
organized daycare
preschool
half-day kindergarten
full day kindergarten
1st grade
Does your child like school?
Yes
No
Has your child repeated a grade?
Yes
No
If yes, which one?
How did your child react to retention?
In your opinion, what is the quality of your child’s school work?
Below average
Average
Above average
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?
Yes
No
Does the school consider your child to have a learning problem?
Yes
No
Does the school consider your child to have a discipline problem?
Yes
No
Does your child like to read (or with you if pre-reading age)?
Yes
No
Visual History
Has the child experienced a recent trauma to their head?
Yes
No
Has the child suffered a recent illness? (cold/flu/Covid)
Yes
No
How long have you noticed the difficulty in your child?
Date of previous eye examination (not at our office):
Reason for previous examination?
Doctor's Name
Date of Exam
Members of family who have had vision or binocular issues and why:
Relationship to patient
Please select
sibling
parent
grandparent
cousin
Diagnosis (for example; myopia/strabismus/amblyopia)
Relationship to patient
Please select
sibling
parent
grandparent
cousin
Diagnosis (for example; myopia/strabismus/amblyopia)
Send
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