VPC – Adult Welcome Questionnaire Vision Performance Center Adult Welcome Questionnaire DateNameMaleFemaleDate of BirthAgeEmail AddressMobile phoneA. Major Concerns1. In your own words, please state briefly your main concern(s) and/or main problem(s) you are having:2. What has occurred that has led you to request an Initial Assessment?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 goals for 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 your 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 writingBetter comprehension when information is heardNot reaching their performance potentialBlurred vision with near visual tasksBlurred vision when looking from desk to distance (far)Holds near work closeEyestrain (eyes hurt, burn or tear) with near tasksRubbing or Blinking eyesHeadaches with near workPoor attentionTired at the end of the dayLoses concentration on near tasksDouble vision with near visual tasksCovering or closing one eye when readingWords move (swim or float) on the pageLoses place with near visual tasksEyestrain (eyes hurt, burn or tear)Rubbing or blinking eyesHeadaches with near workPoor attentionLoses concentration on near tasksPoor reading comprehensionSkipping lines and words routinelyWords appear to jumpUses a guide, ruler or finger when readingLoses place often when readingPoor reading comprehensionShort attention spanAvoids near visual tasksTrouble with right and leftReversing letters and numbersConfusing directionsDifficulty with spellingDifficulty with rhythmic activitiesLack of coordination or balanceDoes not recognize the same word repeated on a pagePoor sight-word recognitionMistakes words with similar beginnings (eg. search for seasonSlow reading speedWhispers to self when readingPoor reading comprehensionPoor recall of visually presented materialTrouble with spellingTrouble following multi-step instructionsPoor attentionMakes careless errors in work tasksEasily distractedAvoiding task that involve sustained mental effort (eg: homework)Trouble copy from board to book (or book to paper)Responds better verbally than in writingKnowing the material but difficulty expressing it in writingB. Educational Information1. In school, did they offer you accommodations for learning?YesNoIf yes, please explain details2. In school, did they give you an Individual Educational Program (IEP)?YesNoIf yes, please explain details3, In grade school, did you have a psychological-educational assessment?YesNoIf yes, please explain details4. Did they give you a diagnosis of "learning disability"?YesNoIf yes, please explain details5. Did they give a diagnosis of "dyslexia"?YesNoIf yes, please explain details6. Did they give a diagnosis of "ADD/ADHD"?YesNoIf yes, please explain details7. Have you had a psycho-education evaluation done?YesNoIf yes, please explain details8. Please indicate any additional educational information that you feel may be helpful: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. What significant childhood illness/issues did you experience?High FeverSignificant infectionsLong periods of hospitalizationToxinsInjuriesPhysical impairmentChronic Ear InfectionsOtherNoneDetails2. Do you have a history of epilepsy or seizures?YesNoIf yes, please explain the details3. Do you have frequent periods of extreme fatigue?YesNoIf yes, please explain the details4. Does fatigue result in sluggishness, excitability or irritability?YesNoIf yes, please explain the details5. What allergies do you have?FoodSeasonalEnvironmentalDrugOtherNoneDetails6. 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 monthotherDetails7. Do you have asthma?YesNoDetails8. 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 monthotherDetails9. Have you been diagnosed with AD/HD (attention-deficit disorder/hyperactive disorder)?YesNoDetails10. What AD/HD medication do you take?a. MethylphenidateRitalinConcertaAdderallb. Tricyclic AntidepressantsWellbutrinc. Norephinephrine Reuptake InhibitorsStratterad. Othere. How often?dailytimes per weektimes per monthotherDetails11. Do you have any significant current medical issues?YesNoIf yes then:What?Treatment?Main Outcomes?OtherDetails12. Are you taking any medication at present?YesNoIf yes then:What?Treatment?Main Outcomes?OtherDetails13. Have you ever had a reaction to medication?YesNoIf yes, then please describeD. Developmental History/Milestones1. Did you meet most of the developmental milestones at the appropriate age?YesNoIf no, then please explain2. Please check below any Gross Motor Skills that were challenging growing up.Learning towalkrunwalk up and down stairswalk stairs with alternate feetride a bikeNone3. Please check the age-range of your child attaining Fine Motor SkillsLearning tocopy a circlebutton clothescatch a balltie shoe lacesNone4. Please check below any Language (expressive and receptive) skills that were challenging growing up.Learning touse two-word sentencestalkNoneE. Previous Assessments and Treatments1. Has there been previous visual care?YesNoIf yes then what?Basic eye examsGlassesPatchingVision TherapyMedicationSurgeryOtherHow consistently?For how long?What effects?OtherDetails2. Have you had a neurological evaluation?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo3. Have you had a speech & language evaluation been done?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo4. Have you had a hearing test been done?YesNoIf yes then when?Main outcomes?4a. Have you had a central auditory processing (CAP) evaluation been done?YesNoIf yes then when?Main outcomes?May a copy be obtained for review?YesNo5. Have you had 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. Family History1. Is there a family history of significant reading, writing, or spelling difficulties?YesNoIf yes thenWho?Details?Other2. Is there a family history of dyslexia?YesNoIf yes thenWho?Details?Other3. Is there a family history of learning disabilities?YesNoIf yes thenWho?Details?Other4. Is there a family history of significant hyperactivity?YesNoIf yes thenWho?Details?Other5. Is there a family history of significant attention problems?YesNoIf yes thenWho?Details?Other6. Is there a family history of significant speech difficulties?YesNoIf yes thenWho?Details?Other7. 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.
