Parent Health Questionnaire
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1
2Health Questionnaire
Ferguson-Florissant School District
Child’s Name
Parent’s Name
Child’s Date of Birth
Age __________
Sex ___________
VISION
Has your child ever had a vision examination or treatment? Yes
No
If yes, when?
By whom?
Results
(A comprehensive vision exam is required before your child enters kindergarten.)
Please check “yes” or “no” to the following observations and/or concerns as they relate to your child:
YES
NO
1. Eyes crossed – turning in or out – at any time, or eyes that do not appear
straight, especially when child is tired………………………………………………….
2. Has reddened eyes or eyelids………………………………………………………….…
3. Has encrusted eyelids…………………………………………………………………….
4. Has frequent sties (pimple on the eyelid)……………………………………………………………
5. Eyes appear to move more than other people’s eyes do………………………………….
6. Eyelids droop………………………………………………………………………………
7. Has white spots or cloudiness covering some or all of the center of the eye.…………
8. Complains of burning, itching, or pain in eyes………………………………………………….
9. Stares at bright lights frequently or repeatedly flicks objects in front of face ………………..
10. Is bothered by light more than you are………………………………………………….
11. The pupil (dark center part of the eye) seems larger than the pupil in other
children’s eyes ……………………………………………………………………………….
12. Complains of headaches or nausea…………………………………………………..……
13. Has watery eyes……………………………………………………………………….……
14. Complains of tired eyes; rubs eyes often……………………………………………..….
15. Moves the head forward or backward while looking at distant objects…………..…
16. Turns the head to use one eye only (closes or covers one eye)………………………..
17. Tilts the head to one side often, or all the time………………………………………….
18. Places an object close to the eyes to look at it……………………………………………….
19. Squints while looking at objects………………..………………………………………….
20. Blinks more than you do………………………………………………………………….
21. Has difficulty walking or running; trips over objects more often than others do….
22. Unable to see distant objects…….……………………………………………………….
23. Seems to see better during the day than at night…………………………………………..
24. Is unable to stack blocks or other objects………………………………………………..
25. There is a history of lazy eye or vision problems in family………………………………..
26. Does anyone in home have a disability or handicap? ………………………………...
Who? ________________________________ What? _____________________________
OVER
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