Vision Screening Online Training Program

Vision History & Questions

Does anyone in the Child’s immediate Family have these conditions?
(Immediate family is defined as a child's siblings, parents, grandparent, aunts, uncles.)

1. Do you suspect anything is wrong with your child's eye/vision?

2. Have any of the immediate family members had eye/vision problems that required treatment before entering school?

Ex. Eye crossing, color vision problems, and/or other types of congenital visual impairments.

3. Have you observed any problems or change in the whites, pupils, lids, lashes or the area around the eyes?

4. Have you noticed any abnormal sensitivity to light, nausea or dizziness or signs/complaints or headaches?

5. Have you noticed any of the following?

a. Turning of one eye (in, out, up or down)

b. Poking at the eyes or frequent rubbing

c. Poor eye contact

d. Covering or closing an eye when looking at an item of interest

e. Abnormal head posture

f. Squinting

g. Moving the head forward, backward or on the horizontal while looking at item of interest

h. Tilting head to one side

i. Placing head close to item of interest

j. Excessive blinking

k. Inaccuracy in reaching for item of interest

l. Unusual tearing

m. Do both of the child’s eyes appear the same in photographs?

n. Has the child been diagnosed with a hearing problem?

6. Circle any of the items below if anyone in your family has any of these conditions?

a. Albinism

b. Amblyopia

c. Anridia/Ankylosing Spondylitis

d. Best Disease

e. Blindness

f. Coloboma

g. Congenital Cataract/ Congenital Glaucoma

h. Diabetes Mellitus

i. Down Syndrome

j. Fetal Alcohol Syndrome

k. Juvenile Macular Dystrophy

l. Marfan Syndrome

m. Myotonic Dystrophy

n. Neurofibromatosis

o. Night Blindness

p. Nystagmus

q. Optic Atrophy

r. Pierre-Robin or Prader Willi Syndrome

s. Retinal Blastoma

t. Retinitis pigmentosa

u. Rubella

v. Sickle Cell anemia

w. Strabismus

x. Sturge-Weber Disease

y. Toxoplasmosis

z. Turner Syndrome/Usher Syndrome/Wilson Disease



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