Fillable Vision and Hearing Questionnaire (Eye and Ear History)

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Vision and Hearing Questionnaire (Eye and Ear History)

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Regional Office of Education #08
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
Vision and Hearing Questionnaire
(Eye and Ear History)
Ch
ild’s Name: _____________________________________ Sex: _______ Age: ______ Date of Birth: ______________________
Mo
ther’s Name: _______________________________________ Father’s Name: _________________________________________
St
reet Address: ____________________________________ City: ______________________ State: ________ Zip: _____________
Pri
mary Phone Number: _________________________________Secondary Phone Number: ________________________________
General Information
1. Did your child weigh less than 5 ½ pounds at birth? Yes No
2. Was there a problem with breathing at birth? Yes No
3. Did your child have yellow jaundice at birth? Yes No
4. Had your child ever had a head injury? Yes No
5. Did the child’s mother have German measles (3 day) during pregnancy? Yes No
6. Please list the names of younger children in the family:
Fa
mily Eye History
1. Has your child ever been seen by and eye doctor? Yes No
If YES, please explain:
Yes
No
Yes
No
2. Does your child wear eyeglasses? Yes No
3. Have you noticed signs which might indicate eye difficulty?
4. Do the child’s eyes look crossed, particularly when tired or ill?
5. Do any of the child’s family members have a crossed eye?
Mother Father Sister/Brother Grandparent
6. Has the child ever had an eye surgery? Yes No
7. Do any of the child’s family members have an eye that is much weaker than the other?
Mother Father Sister/Brother Grandparent
Fa
mily Ear History
1. Do any of the child’s family members have a hearing loss?
Mother Father Sister/Brother Grandparent
2. Has your child ever had a hearing test? Yes
No
Yes No3. Has your child ever had ear infections, earaches, or ear drainage?
4. Does your child have allergies? Yes No
5. Have your child’s tonsils and adenoids been removed?
Yes
No
6. Has your child ever had ear tubes surgically placed?
Yes No
7. Does your child have a hearing loss? Yes No
Form continued on the back!
Name of Primary Care Physician: _______________________________________________________________
Name of (Eye Doctor) <If applicable>: __________________________________________________________
Name of Ear, Nose, and Throat Doctor (ENT) <If Applicable>:
__________________________________________________________
Please describe any additional concerns or information about your child’s hearing or vision:
Screening Results
(Office Use Only)
Hearing 1: P F Attempt 2: P F Could not test
Vision 1: P F
Attempt 2: P F
Could not test
Referred for a medical hearing evaluation? Yes No
Referred for a medical vision evaluation? Yes No
Additional Comments:
Regional Office of Education #08
27 S.
State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
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Vision and Hearing Questionnaire (Eye and Ear History)

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Completed 10 March 2021

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