CHILD/ADOLESCENT STRABISMUS AND MEDICAL HISTORY QUESTIONNAIRE

Transcription

1 BRIER CREEK VISION CARE Susan L. Durham, O.D., F.C.O.V.D. & THE CENTER FOR VISUAL LEARNING & REHABILITATIVE THERAPY Pooja J. Patel, O.D., F.A.A.O Cerny Street, Suite 100 Raleigh, NC (919) phone (919) fax CHILD/ADOLESCENT STRABISMUS AND MEDICAL HISTORY QUESTIONNAIRE Please complete this questionnaire carefully and return it to our office as soon as possible. GENERAL INFORMATION Patient s Full Name: Male Female : Age: years months School: Grade level: Please list the names and birth dates of patient s family members: Father/Caretaker Mother/Caretaker RESPONSIBLE PERSON INFORMATION Home Address: City: Zip: Father/Caretaker s Occupation: Business Phone: Father s Address: Father s Cell Phone: Mother/Caretaker s Occupation: Business Phone: Mother s Address: Mother s Cell Phone: Do you have Major Medical Insurance? Yes If so, who is the carrier? Policy #: Name of Insured: Date of birth: Social Security Number: Were you referred to our office? Yes If yes, whom may we thank for this referral? MEDICAL HISTORY Pediatrician s Name: Date of Last Evaluation: Current medications and reason for taking them (including vitamins and supplements): Drug Allergies: List illnesses, bad falls, high fevers, etc. (include age at occurrence): Is your child generally healthy? Yes If not, explain: 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years - 1 -

2 Are there any chronic problems like ear infections, asthma, hay fever, allergies? Yes If yes, please list: Has a neurological and/or psychological evaluation been performed? Yes By whom? Results and recommendations: Has a psychoeducational evaluation been performed? Yes By whom? Results and recommendations: Has an occupational therapy evaluation been performed? Yes By whom? Results and recommendations: Has a speech therapy evaluation been performed? Yes By whom? Results and recommendations: MEDICAL HISTORY: Patient Family Relation/Details High Blood Pressure Heart Disease High Cholesterol Stroke Diabetes/Endocrine Blood/Lymphatic Arthritis Cancer (type) Lung Disease (asthma/emphysema) Thyroid Disease GI disease (ulcers/acid reflux) Infectious disease (HIV/hepatitis) Acquired/Traumatic Brain Injury Ear, nose, throat (allergies) NA Kidney, Bladder, Genital NA Neurological NA Depression NA Anxiety NA Surgeries: (list) OCULAR HISTORY: Patient Family Relation/Details Glaucoma Cataracts Macular degeneration Retinal disorders 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years - 2 -

3 Patient Family Relation/Details Blindness Strabismus/eye turn Amblyopia/lazy eye Eye injuries Eye surgeries Others: (list) DEVELOPMENTAL HISTORY Full-term pregnancy: Yes Normal birth: Yes Birth weight: Did the mother experience any health problems during the pregnancy? Yes If yes, explain: Were there any complications before, during or immediately following delivery? Yes If yes, explain: Were forceps used? Yes Was there ever any reason for concern over your child s general growth or development during the first year of life? Yes If yes, why? Did your child crawl (stomach on floor)? Yes At what age? Did your child creep (on all fours)? Yes At what age? At what age did your child walk? Speech concerns at this time? Yes VISUAL HISTORY Why do you feel your child needs a vision examination? Speech: At what age: Has your child s vision been previously evaluated? Yes If yes, Doctor s name: Date of last evaluation: Were glasses, contact lenses, or other optical devices recommended? Yes If yes: single vision line bifocal no-line bifocal contact lenses Other Are they worn? Yes If yes, when? If no, why not? If contact lenses are worn, what type are they? Soft Rigid Gas Permeable If soft, how often are they replaced? daily 2 weeks monthly 3 months yearly How long have contacts been worn? If not worn full time, when are they worn? How old are the current contact lenses? What solutions are used? Are there any problems with the current optical prescription? Yes If yes describe: 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years - 3 -

4 At what age was it first noticed or suspected that an eye was turning? Was there any related trauma, disease, or condition that preceded or accompanied the onset of the eye turn? Yes If yes, please explain: Did the eye begin turning suddenly or gradually? Does the eye turn: in out up down (check all that apply) Is the eye turn: worsening improving stable Is it always the same eye that turns? Yes If yes, which eye? Right Left Is the eye turn always present? Yes If no, under what conditions is it present? Has amblyopia (lazy eye) been diagnosed? Yes Has there been any treatment using an eye patch? Yes If yes, please describe when the patching was started, how the patching was done, including the age it started, the eye patched, the duration of treatment, and the results: Has there been any surgical treatment? Yes If yes, please list the age surgery was performed, the number of operations, the eye(s) on which surgery was performed: Were the results of the surgery satisfactory? Yes Explain: Have surgical results been maintained? Yes Explain: Has there been any vision therapy? Yes If yes, list dates of vision therapy and Doctor s name: Results of therapy: Is this appointment for a second opinion on surgery or other forms of treatment? Yes Are any of the following symptoms reported? Yes No If yes, when? Difficulty seeing distance objects Vision gets blurry when reading Frequent eye rubbing Excessive blinking Red/bloodshot eyes Eyes water Eyes itch Eyes burn 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years - 4 -

5 Are any of the following symptoms reported? Yes No If yes, when? Bothered by light Eyes feel strained after short periods of reading or close work Fatigues quickly when reading Dislikes or avoids reading/close work Reads slowly Letters/words run together/move when reading Loses place or omits words when reading Rereads or skips lines unknowingly Needs finger/marker to keep place reading Holds head close to paper when reading/writing Complains of seeing double Closes or covers one eye when reading Tilts or turns head to one side excessively Gets headaches when reading Motion sickness Car sickness Short attention span Reverses letters, numbers or words Confuses right and left Sloppy handwriting Excessive erasures Awkward or immature pencil grip Fails to recognize same word in next sentence Difficulty copying from the board Poor ability to remember what is read Difficulty with memory Difficulty judging distances Difficulty hitting and/or catching a ball SCHOOL Has a grade been repeated? Yes If yes, which and why? Seems to be under tension or extreme pressure when doing school work? Yes Have there been any special tutoring, therapy, and/or remedial assistance? Yes If yes, describe: 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years Does the patient read voluntarily? Yes What is the patient s attitude towards school/teachers/classmates? Overall schoolwork is: above average average below average Is a lot of time/effort spent to maintain this level of performance? Yes How much time on average is spent each day on homework assignments? To what extent does a parent assist the patient with homework? Do you feel the patient is achieving up to potential? Yes Does the teacher feel that patient is achieving up to potential? Yes

6 TELEVISION VIEWING/LEISURE TIME ACTIVITIES How much time is spent watching TV, or playing on computer/video games per day? What other activities occupy patient s leisure time? GENERAL BEHAVIOR Are there any behavior problems at school? Yes Are there any behavior problems at home? Yes What causes these problems? If yes, what? If yes, what? FAMILY AND HOME Please indicate which adult(s) patient lives with? Mother Father Stepmother Stepfather Foster Parents Adoptive Parents Grandmother Grandfather Aunt Uncle Other Caretaker (please specify): GIVE A BRIEF DESCRIPTION OF PATIENT AND PLEASE ADD ANY OTHER INFORMATION THAT WOULD BE HELPFUL OR IMPORTANT FOR OUR TREATMENT: For Office Use Only O.D. Initial Date: 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years - 6 -

7 RELEASE OF INFORMATION AND INSURANCE FILING IT IS OFTEN BENEFICIAL FOR US TO DISCUSS EXAMINATION RESULTS AND TO EXCHANGE INFORMATION WITH YOUR CHILD S SCHOOL AND/OR OTHER PROFESSIONALS INVOLVED IN HIS/HER CARE. PLEASE SIGN BELOW TO AUTHORIZE THIS EXCHANGE OF INFORMATION. I agree to permit information from, or copies of, my child s examination records to be forwarded to my child s school, other health care providers or insurance carriers upon their written request or upon the recommendation of Brier Creek Vision Care when it is necessary for the treatment of my child s visual condition, or for the processing of insurance claims. This authorization shall be considered valid throughout the duration of treatment by means of my signature as indicated below. Signature Date Relationship to patient I hereby give my permission to Brier Creek Vision Care to treat (Child s Name). Parent s or Guardian s Signature Date Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us to better meet your child s specific visual needs. If you have any questions or concerns that we may answer prior to your appointment, please do not hesitate to contact us. You may leave a message for us 24 hours a day/7 days a week. We request a minimum of 24 hours notice if you are unable to keep this appointment. Missed appointment fee is $50 without 24 hour notice. Please be on time for your examination, so that we will have the maximum opportunity to evaluate your child s visual status. THANK YOU. The Staff of Brier Creek Vision Care & The Center for Visual Learning & Rehabilitative Therapy 2017 Child/Adolescent Strabismus Questionnaire Ages 5-18 years - 7 -