Foley Vision Center
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Infant/Toddler Developmental History Form

Thank you for carefully completing this questionnaire. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your child's visual system related to his/her specific needs.
GENERAL INFORMATION
Child's full name:
Nickame:
Date of birth:
Is your child especially afraid of Doctors? Yes No
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiin or Other Pacific Islander
White
Unknown/Decline to Provide
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Decline to Provide
Preferred Language: English
Spanish
Other:

Per the Health Care Act we are required to record your height and weight at each visit.
Height: Weight:
MEDICAL HISTORY
Has your child been prone to infection? Yes No     Doctor Name
Chronic problems like hay fever,
asthma, or allergies?
Yes No
List illnesses, bad falls, high fever, asthma or allergies:
Age Condition Severe Mild
Has a Neurological evaluation been performed? Yes No     Date
By whom? Results
Has a Psychological evaluation been performed? Yes No     Date
By whom? Results
DEVELOPMENTAL HISTORY
Birth weight
Full term pregnancy? Yes No
Normal birth? Yes No
Were forceps used? Yes No
Did the mother have any
health difficulties during the pregnancy?
Yes No
Any birth complications? Yes No
Is this an adopted child? Yes No
Any special circumstances
we should be aware of?
Yes No
If yes, explain:
Is your child alert? Yes No
Was there ever a reason for concern over
your child's general growth or development?
Yes No
If yes, why?
Where appropriate, list your child's age when he/she could do the following:
Responsive smile
Sit up (without support)
Creep (stomach off floor)
Crawl (stomach on floor)
Responded to words or names
Stacked blocks
Walked up steps with help
Gave first name
Became toilet trained
Rolled over
Walked (without support)
Talk (string two words)
Good "all-fours crawling"?
Said single words
Scribbled spontaneously
Kicked a ball
Used two-word sentences
Put on some clothing alone
What percent of the waking hours is your child in a:
playpen?
walker?
seat?
Does your child run a lot? Yes No
Does running seem aimless? Yes No
What hand does your child prefer to use eating? Right Left
What things can your child do very well?
What things, if any, are difficult for your child?
NUTRITIONAL INFORMATION
What is your child's activity level? Low Moderate High
Current diet: Nursing:
Never
Now
Nursed Until
Solid food started
What type
Have you noted extreme fatigue? Yes No
   If so, when?
Does fatigue result in a sag,
excitability or irratibility?
Yes No
Is your child's visual difficulty
more noticeable with fatigue?
Yes No
Is there any tensional behavior such as nail biting,
eye blinking or rubbing (other than normal sleepiness),
tantrum, tongue chewing or extension?
Yes No
If so, when?
Do any of these tensional behaviors seem
related to preschool, movies or TV?
Yes No
PRESENT SITUATIONS
Please check YES or NO to the following observations and/or complaints as they relate to your child:
Symptom:  Yes  No If so, when?
1. Eves crossed-turning in or out at any time or eyes that do not appear straight, especially when child is tired.
2. Has reddened eyes or eyelids
3. Has encrusted lids
4. Has frequent sties
5. Eyes in constant motion
6. Eyelids droop
7. Complains of burning or itching eyes
8. Complains of pain in eyes
9. Stares at bright lights frequently
10. Is abnormally bothered by bright lights
11. Has watery eyes
12. Thrusts the head forwards or backwards while looking at distant objects
13. Turns the head to use one eye only
14. Tilts the head to one side
15. Squints while looking at objects
16. Blinks excessively
17. Has a tendency to rub eyes
18. Covers or closes one eye
19. Stumbles over objects
20. Lacks interest in looking at objects or seeing
21. Unable to see distant objects
22. Transfers objects from hand to hand, crossing the middle of the body
23. Is unable to stack blocks or other objects
How much television viewing?
How often?
Viewing distance?
Members of the family who have had visual attention and why:
Name Age Visual Situation
GENERAL BEHAVIOR
Do you have any concerns
about your child's behavior?
Yes No
If so, what are they?
Has there been any recent
or ongoing emotional difficulties?
Yes No
If so, describe:
Check the appropriate boxes if you have any concerns about the following behavior(s) in your child:
Lack of curiosity
Thumb sucking
Nervous
Glum, sulky, moody
Bad temper
Irritable, easily upset
Restlessness
Has difficulty separating from parents
Sleeplessness
Other
FAMILY AND HOME
Family Member Birth Date/
Age
Visual Situation
Is there any history of mental retardation, psychological disturbance, etc., in the family?
Please use this space to write a brief description of your child as a person.
Our goal is to provide the best, most complete, up-to-date care available. Our philosophy is preventive and developmental in approach. To provide this service in the most efficient manner, please be aware of the following office policies:
  • Fees for services are due at the time those services are rendered.
  • Payment in full at time of ordering.
  • We reserve the right to charge for missed appointments not canceled in advance.
  • Vision Therapy patients must notify us of absences in advance.
  • There is a charge for written reports.
  • Responsibility for payment is the patient's. Insurance agreements are between the company and the patient. We will assist with proper forms but require reimbursement from patients.
Signed (type your name):
Date: