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Home » Patient Forms » Preschool Questionnaire

Preschool Questionnaire

MM slash DD slash YYYY
Child's Name
Professional's Name
Please rate the following signs and symptoms according to your current observations and/or your patient's current reports about how his/her eyes feel. Indicate the frequency of these signs and symptoms using the following number scale:
Score 0 for Never, 1 for Infrequently, 2 for Sometimes, 3 for Fairly Often, 4 for Always
Complaints of tired eyes during or after close work(Required)
Complaints of eyes hurting during or after close work(Required)
Complaints of headaches during or after doing close work(Required)
Complaints of being tired during or after doing close work(Required)
Distracted/inattentive when doing close work(Required)
Reports seeing double when doing close work(Required)
Frequent tilting of the head(Required)
Frequent rubbing of the eyes(Required)
Squinting when looking at objects(Required)
Consistently sitting close to the TV or holding a book to close(Required)
Holding objects close to their nose to view(Required)
Closing one eye to read, watch tv, or see better(Required)
Turning of an eye in or out(Required)
Poor eye hand coordination(Required)
Avoidance of table top work such as coloring, puzzles, other detailed activities(Required)
Difficulty completing tasks/assignments in a timely manner(Required)
Seems to be clumsy or knock things over(Required)
Overly cautious on steps or curbs(Required)
Short attention span/easily distracted for the child's age(Required)
Not reaching their academic potential(Required)
**Total scores greater than or equal to 13 warrant a consultation with a Developmental Optometrist specializing in the diagnosis and treatment of Vision-Related Learning Problems.