Pre-VT Survey Patient's Name:*Survey Being Completed By:*MotherFatherPatient Dear Parent, We look forward to helping you and your child solve and eliminate the visual problems that have interfered with your child's academic performance. Completing this survey will help us learn more about your child so that we can help you and your child the most. Please also complete the Functional Vision Lifestyle Checklist hereDear Patient, We look forward to helping you solve and eliminate the visual problems that have interfered with your life, such as the ability to read, work, drive, etc. Please fill out this survey so that we will be able to learn about you and help you the most. Please also complete the Functional Vision Lifestyle Checklist herePlease describe your child's condition.Please describe the kinds of problems that YOU feel he or she has. Please describe the kinds of problems that YOUR CHILD feels he or she has. Please include information on what life is like with regards to: school, sports, at home, etc.Please describe your condition.Please include information on what life is like with regards to work, reading, driving, sports, etc.What prompted you to seek help at our office?What steps had you previously taken to get help?Was your child behind in school? If yes, how far?When did your symptoms begin? Was it after an accident or medical episode such as a stroke? Do you feel that you always had these problems?Was your child working with a tutor or receiving special services at school? Were they helping? (Please describe)Was your child classified as learning disabled, ADD/ADHD, or some other label?Were you ever classified as learning disabled, ADD/ADHD, or some other label?Has medication ever been prescribed?YesNoFor how long? Do you feel the medication was helping?Prior to your visit with our office, was there an evaluation performed by another eye care professional?YesNoWhat were the findings?Do you feel that your child is performing to potential? What areas do you feel he or she should / could be doing better in?What specifically would you like to see improved? What are your goals that you would like to achieve through vision therapy?Are there any behaviors that you would like to see improved?For example: frustration, whining, taking longer to complete homework, school assignments, tests, feelings of inferiority or poor self-esteem?Has your child's teacher spoken with you regarding your child? Can you share some specific comments made?Additional comments:
