Teacher Questionnaire

Important information, please read:

• Teachers usually have had the opportunity to observe the child in many different situations and may be in a situation to notice some difficulties experienced by the child.
• The following is a checklist of symptoms that have been found to be frequently associated with a vision problem. It is a combined form for all grade levels including preschool.

Before your appointment

• You must fill out the digital form below before the child’s appointment date.
• If you prefer to fill out the form by hand, you can download and print the Teacher Questionnaire PDF for the parent to bring to the child’s appointment.

Teacher Pre-Examination Questionnaire

Please read through the relevant sections according to the child’s grade and developmental level and check those items you have noticed in this child’s case.

Consent(Required)

You have been granted permission for the release of confidential information regarding the child, by the parent or guardian.

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Teacher's Name(Required)

First Last

Teacher's Email(Required)

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Child's Name(Required)

First Last

School(Required)

Grade(Required)

Appearance of eyes

One eye turns in or out at any time

Reddened eyes or lids

Watery eyes

Which eye?

Left

Right

Body posture and space awareness

Unusual awkwardness

Frequent tripping or stumbling

Confuses right or left directions

Improper or awkward posture while writing

Improper or awkward posture while reading

General behaviour

Complains of headaches

Dislikes tasks requiring sustained visual concentration

Avoids close work or tasks

Irritability or restlessness after close work

Daydreaming or inattentiveness

Blinks excessively

Frowns, scowls or squints

Covers one eye

Closes one eye

Complains of double vision

Rubs eyes frequently

Tilts head to one side

Which eye?

Left

Right

Which eye?

Left

Right

Regarding Pre-school or 1st Grade child

Inadequate development for age in any of the following skills:

Colouring activities

Cutting

Painting

Block Play

Puzzle Play

Outside Play

Climbing

Eye Movement Abilities

Head turns as reads across page

Lose place frequently during reading

Needs finger or marker to keep place

Short attention span in reading or copying

Frequently omits words

Writes up or downhill on paper

Rereads or skips lines unknowingly

Orients drawing poorly on page

Visual Perceptual Function

Fails to recognize same word in next sentence

Reverses letters & or words in writing & copying

Difficulty recognising minor differences

Repeatedly confuses words with similar beginnings and endings

Fails to visualise what is read silently or aloud

Uses tracing with fingers to discriminate similarities and differences

Eye Teaming Abilities

Repeats letter within words

Omits letters, numbers or phrases

Misaligns digits in number columns

Squints, closes or covers one eye

Tilts head extremely while working at desk

Refractive Status (Short or Long-sightedness, focus problems, etc.)

Quickly loses interest in reading

Blinks excessively at desk tasks or reading

Blinks to clear board after reading or writing

Holds book too closely; face too close to desk

Makes errors in copying from the board

Makes errors in copying from page to paper

Squints to see board, or requests to move nearer

Rubs eyes

Eye-Hand Coordination Abilities

Must feel things to get the idea

Eyes not used to “steer” hand movements(extreme lack or orientation, placement of words or drawings on page)

Writes crookedly, poorly spaced; cannot stay on ruled lines or misaligns both horizontal and vertical series of numbers

Uses hand as spacer to control spacing and alignment on page

Repeatedly confuses left-right directions

Difficulties with ball-handling in sport

Visual Stress

Complains that print is moving

Says letters change size or shape

Describes Illusions of colour—blobs of colour appear on the page or colours surround letters or words

Says patterns appear on the page, through or around the print

Excessive sensitivity to lighting in classroom

In your opinion, is this child performing at his/her potential?

Does this child perform better with written tasks or verbal tasks?

What are this child’s strengths academically?

Does this child have any relative weakness academically?

If you can, could you give an estimation of this child’s approximate reading age?

Are there any other personal impressions about this child that you feel may be helpful to our assessment?

Date(Required)

Day

Month

Year

Signature

Name

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