FLC – Welcome Intake Questionnaire Foundations for Learning Centre Child Welcome Questionnaire DateNameMaleFemaleDate of BirthAgeName of SchoolGradeTeacher(s)ParentsMother's NameEmail AddressMobile phoneFather's NameEmail AddressMobile phoneStatusMarriedSeperatedDivorcedOtherLanguages Spoken at HomeEnglishOtherA. Major Concerns1. In your own words, please state briefly your main concern(s) and/or main problem(s) your child is having:2. What prompted you to request an Initial Assessment for your child?3. Who first noted the visual difficulties?When?4. Whose idea was it to come in for an Initial Assessment?ParentTeacherSchoolDoctorFriendOther5. What are your expectations or goal for your child with vision therapy?6. Please indicate any additional information that you feel may be helpful:7. Please place a check mark next to any problems that seem to occur often with your child. (Some items are repeated, please check mark them again)Working twice as hard to reach their academic successPoor reading performanceDifficulty finishing written work in the allotted amount of timeEasily distractedPoor attentionDifficulty copying from board to paper or from book to paperResponds better verbally than in writingSeems to know the material but does poorly written testsBetter comprehension when story is read to themStruggling in schoolNot reaching their academic potentialBlurred vision with near visual tasksBlurred vision when looking from desk to boardHolds near work closeEyestrain (eyes hurt, burn or tear) with near tasksRubs or blinks eyesHeadaches with near workPoor attentionTired at the end of the dayLoses concentration on near tasksDouble vision with near visual tasksCovers or closes one eye when readingComplains of words moving (swimming or floating) on the pageLoses place with near visual tasksEyestrain (eyes hurt, burn or tear)Rubs or blinks eyesHeadaches with near workPoor attentionLoses concentration on near tasksPoor reading comprehensionSkips or repeats lines and words routinelyWords appear to jumpUses a guide, ruler or finger when readingLoses place often when readingMoves head excessively when readingPoor reading comprehensionShort attention spanAvoids near visual tasksTrouble learning right from leftReverse letters and numbersConfuses directionsDifficulty learning the alphabet or single numbersDifficulty with spellingDifficulty with rhythmic activitiesLack of coordination or balanceTrouble writing or recognizing letters and numbersDoes not recognize the same word repeated on a pagePoor sight-word recognitionMistakes words with similar beginnings (eg. search for seasonTrouble learning math basicsSlow reading speedWhispers to self when readingPoor reading comprehensionPoor recall of visually presented materialTrouble with spellingTrouble following multi-step instructionsFails to pay attentionMakes careless errors in school workEasily distractedAvoids task that involve sustained mental effort (eg: homework)Trouble copy from board to book (or book to paper)Excessive erasingResponds better verbally than in writingSeems to know the material but does poorly on written testsB. Educational Information1. Grade Level1234567891011122. Grades on last report cardOverallSpellingMathReadingLanguage Arts3. Last report card's performance-level.TypicalImprovedLower4. Areas of Strength in school5. Areas of Weakness in school.6. Any repeated grades?YesNoIf yes, then what grade?7. At what age did your child begin (please circle year)Nursery School?2345Junior Kindergarten?456Senior Kindergarten?456First Grade?45678. Has your child had excessive absent days from school?YesNoIf yes, then how long and why:9. Please indicate type of classroom setting:MainstreamPartial InclusionResourceSelf-containedHome-schooled10. Has your child been provided with any school accomodations?YesNoIf yes, then what?11. has your child been provided with an Individual Education Plan (IEP)?YesNoIf yes, then what are the details?12. In comparison to your child's school classmates/peers, how would you rate your child's school performance?Above AverageAverageBelow AverageOther13. In your opinion, what is your child'sBest subject?Easiest subject?Hardest subject?14. If there is difficulty at school, what do you think are the reasons?15. What does your child say or feel about school or school work?16. Has the teacher reported anything about your child's school work?YesNoIf yes, then what?17. Please check the best answer to the following questions:Does your child like school?YesNoMaybeDoes your child like his/her teacher?YesNoMaybeDoes your child attend school regularly?YesNoMaybeIs your child attending the grade level expected for his/her age?YesNoMaybeDoes your child read as well as others in the same grade?YesNoMaybeIs the teacher satisfied with your child's performance?YesNoMaybeAre you satisfied with your child's performance?YesNoMaybeIs his/her performance up to potential?YesNoMaybe18. What are your child's special interests?C. Medical HistoryThe information gathered in this section helps Dr. Gall identify particular circumstances that may contribute to learning difficulties, or put a child at a higher risk. It helps Dr. Gall to identify possible referrals to another professional for further assessment.1. Were there any significant maternal health, pregnancy or environmental issues leading to birth?YesNoIf yes then what?2. Was the pregnancy of your child full-term?YesNoIf no then please explain:3. Child's birth weight?PoundsOuncesGrams4. Were there any significant birth-delivery issues?YesNoIf yes, then what?5. Were there any significant post-delivery issues?YesNoIf yes then what?JaundiceInfectionBirth DefectsIncubation CareOtherIf incubation care, How many days?Details6. Did your child leave the hospital with the mother?YesNoIf no, then please explain:7. What significant childhood illness/issues have occurred?High feverSignificant infetionsLong periods of hospitalizationToxinsInjuriesPhysical impairmentChronic ear infectionsOtherNoneDetails8. Does your child have a history of epilepsy or seizures?YesNoIf yes, please explain the details9. Does your child have frequent periods of extreme fatigue?YesNoIf yes, please explain the details10. Does fatigue result in sluggishness, excitability or irritability?YesNoIf yes, please explain the details11. What allergies does your child have?FoodSeasonalEnvironmentalDrugOtherNoneDetails11a. What anti-allergy medication does your child take (over-the-counter or Rx'd)?a. Anti-histamine, H1 receptor antagonist (anti-cholinergic effect)Claritin (loratadine)Reactine (cetirizine)Aerius (desloratidine)Benadryl (diphenhydramine)b. Sudafed (pseudoephedrie)c. EpiPend. Otherdailytimes per weektimes per monthotherDetails12. Does your child have asthma?YesNoDetails12a. What anti-asthma medication does your child take (over-the-counter or Rx'd)?a. Short-acting Beta-2 adrenergic agonists (bronchial muscle relaxer)Alromir (salbutamol)Ventolin (salbutamol)Bricanyl Turbuhaler (terbutaline)b. Theophylline-Type Drugs (xanthine derivative, related to caffenine)Somophyllin-12 (theophylline)Theo-Dur (theophylline)Uniphyl (theophylline)Choledyl (oxtriphylline)Phyllocontin (aminophylline)c. Anti-Cholinergic MedicationAtrovent (ipratropium bromide)d. Inhaled corticosteroid & long-acting Beta-2 agonist (ICL/LABA)Symbicort® Turbuhaler (budesonide/ formoterol) ___Advair® (pMDI) (fluticasone/ salmeterol)Zenhale (mometaseone/ formoterol)e. Otherf. How often?dailytimes per weektimes per monthotherDetails13. Has your child been diagnosed with AD/HD (attention-deficit disorder/hyperactive disorder)?YesNoDetails13a. What AD/HD medication does your child take?a. MethylphenidateRitalinConcertaAdderallb. Tricyclic AntidepressantsWellbutrinc. Norephinephrine Reuptake InhibitorsStratterad. Othere. How often?dailytimes per weektimes per monthotherDetails14. Does your child have any significant current medical issues?YesNoIf yes then:What?Treatment?Main Outcomes?OtherDetails15. Is your child receiving any medication at present?YesNoIf yes then:What?Treatment?Main Outcomes?OtherDetails16. What medications (such as penicillin or sulfa drugs) have been given and for what?17. Has your child ever had a reaction to medication?YesNoIf yes, then please describeD. Developmental History/Milestones1. Did your child meet most of the developmental milestones at the appropriate age?YesNoIf no, then please explain2. Please check the age-range of your child attaining Gross Motor Skills* expected agesRolls Over01234*5*678910MonthsSits without support0123456*7*891011MonthsPulls self to stand789*10*111213MonthsWalks independently9101112*13*14*151617MonthsRuns11.5*2*2.5YearsPedals tricycle23*45YearsWalks up and down stairs - alternate feet33.5*4*4.555.5YearsRides bicycle no training wheels56*7*89Years2a. Does your child like to participate in sports activities?YesNoIf no, then please explain3. Please check the age-range of your child attaining Fine Motor Skills* expected agesTransfers object from hand to hand23*4*5*678MonthsHolds bottle56*789MonthsPincer grasp (pointer and thumb)78910*11*12*1314MonthsThrows objects to the floor1112*13*14*15*161718MonthsScribbles11.5*2*2.5YearsCopies a circle23*45YearsButtons clothes23*4*5*67YearsCatches a ball34*5*67YearsTies shoelaces345*6*78Years3b. Was early building-block play good?YesNoIf no, the please explain3b. Was early building-block play good?YesNoIf no, the please explain3c. Do building sets, puzzles, colouring and cutting hold attention?YesNoIf no, then please explain4. Please check the age-range of your child attaining Language (expressive and receptive) skills.* expected agesPays attention to familiar voices23*4*5678MonthsBabbles45*6*789MonthsUses "ma-ma" and "pa-pa" correctly101112*1314MonthsRecognizes names of common objects111213*14*15*161718MonthsFollows simple commands131415*16*17*18*1920MonthsUse simple three-word sentences (subject, verb and object)23*4*5YearsName primary colours accurately234*56YearsVocabulary of 2000 to 2500 words45*67YearsAsks "why"?45*67YearsCounts to 1045*67Years4a. Was your child's early speech clear?YesNoIf no, then please explain:4b. Could others besides the family understand your child's early speech?YesNoIf no, then please explain:4c. How would you rate your child's speech currently?AdvancedNormalBelow NormalPlease explain further:E. Previous Assessments and Treatments1. Has there been previous visual care?YesNoHow consistently?For how long?What effects?OtherDetails2. Has you child ever had a neurological evaluation?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo3. Has a psycho-education evaluation been done?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo4. Has a speech & language evaluation been done?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo5. Has a hearing test been done?YesNoIf yes then when?Main outcomes?5a. Has a central auditory processing (CAP) evaluation been done?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo6. Has an occupational therapy (OT) evaluation been done?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo7. Have any remedial/therapy approaches been tried?YesNoIf yes then what?Speech and languageOccupational therapyReading remediationResourcePrivate tutoringOtherHow Consistently?For how long?What effects?OtherDetailsF. Behavior and Attention1. Did your child have any early behavioral problems (temper tantrums, self-destructive behavior, difficulty sleeping, etc.)?YesNoIf yes, then please explain:2. Does your child exhibit any anxiety-behavior such as nail biting, eye blinking or rubbing, tantrums, tongue chewing or lip biting, etc?YesNoIf yes, then please explain:3. Has your child been diagnosed of ADHD (attention deficit/hyperactivity disorder)?YesNoIf yes thenWhen?Treatment?Main outcomes?OtherDetails4. Please indicate any additional information that you feel may be helpful:G. Family History1. Does your family spend time reading?Parent to childChild to parentSelf readingOtherPlease explain further2. Is there a family history of significant reading, writing, or spelling difficulties?YesNoIf yes thenWho?Details?Other3. Is there a family history of significant hyperactivity?YesNoIf yes thenWho?Details?Other4. Is there a family history of significant attention problems?YesNoIf yes thenWho?Details?Other5. Is there a family history of significant speech difficulties?YesNoIf yes thenWho?Details?Other6. Please indicate any additional information that you feel may be helpful:H. Other InformationPlease indicate any additional information that you feel my be helpful:Thank you for spending the time to help us better understand your child.Sincerely, Dr. Ronald Gall OD, MSc, FAAO, FCOVD, Diplomate BVPPOSignatureStart signing your signature hereYour browser does not support e-Signature field.Consent *Yes, I agree with the privacy policy and terms and conditions.Submit FormPlease do not fill in this field.
