Children's Pre-Examination Questionnaire     Childs Name Birth Date             School Grade Teacher Name and age of children in family Mother's Occupation       Father's Occupation        Whom may we thank for refferring you? I. Please state the major reason you would like this child examined? III. School  (Please Select Yes or No)             Yes No     1. Does Child Like School?     2. Does child like teacher?     3. Is school satisfied with child's performance?     4. Are you satisfied with child's performance?     5. Has a grade been repeated? III. Development  (Please Check for YES)     A. Has your child had:         1. Any severe childhood illness such as high fever, injury, or physical/mental impairment? Yes   No     B. Were there any birth complications or a difficult pregnancy? Yes   No     C. At what age in years and months did the child:         Speak Words Clearly                Walk unaided     Which phrase describes the child's physical maturity (Please Select one) 1. Physically Immature for age 2. Average physical maturity for age 3. Advanced physical maturity for age IV. Academics     A. Rate the child's progress in the following subjects: Reading    Below Average Advanced Spelling    Below Average Advanced Writing    Below Average Advanced Arithmetic    Below Average Advanced     B. Has there been any intervention (therapy, special programs) for a learning programs? Yes   No V. Behavior. Please rate this child on the following items. Choose a number in the blank to the left of item which describes the child's school or home behavior.        Always Frequently Occasionally Rarely Never Unknown Hyperactive        Always Frequently Occasionally Rarely Never Unknown Short attention span        Always Frequently Occasionally Rarely Never Unknown Easily frustrated        Always Frequently Occasionally Rarely Never Unknown Emotional problems        Always Frequently Occasionally Rarely Never Unknown Poor peer relationships        Always Frequently Occasionally Rarely Never Unknown Indistinct speech        Always Frequently Occasionally Rarely Never Unknown Akward or clumsy        Always Frequently Occasionally Rarely Never Unknown Poor ability to organize work        Always Frequently Occasionally Rarely Never Unknown Rubs Eyes        Always Frequently Occasionally Rarely Never Unknown Holds book closer for reading        Always Frequently Occasionally Rarely Never Unknown Variable school performance        Always Frequently Occasionally Rarely Never Unknown Behavior fluctuations or problems        Always Frequently Occasionally Rarely Never Unknown Difficulty completing school work        Always Frequently Occasionally Rarely Never Unknown Confusion with verbal instructions        Always Frequently Occasionally Rarely Never Unknown Reverses letters, words or numbers in reading and or writing VI. Medical/Visual History     A. Has Child received a hearing test? No   Yes   Date:   Results:     B. Has Child received a complete eye exam? No   Yes   If yes, please explain:   Results:     C. Does the child have any allergies? No   Yes   If yes, please explain:   Results:     D. Is the child currently taking any medications? No   Yes   If yes, please list medication, dosage, and purpose for each:   Results: VII. Release of Information. If you wish a copy of exam results to be sent, please provide name and address.       Name              Address        City State Other AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY Zip Parent/Guardian Permission By checking the box below I certify that I am a Parent/Guardian of the child lised above, and authorize the release of the test results.