Parent Input on Vision

Hello! Thank you for taking time to talk about your child's vision! 

If a question is not applicable or age appropriate for your child, just select "Not Applicable".


If you have any questions, you're welcome reach out to mary.morrell@msb.dese.mo.gov

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* 1. What is your name?

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* 2. What is your email address?

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* 3. What is your child's name?

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* 4. Does your child ever have problems getting around when its dark/ in dim lighting?

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* 5. Does your child ever have problems or complain about bright lights?

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* 6. How does your child adjust to different lighting? 
(Example: when you walk from the shade into the sun)

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* 7. Does your child have trouble getting around in unfamiliar environments or new places?

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* 8. Can your child travel independently outdoors?

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* 9. What kinds of recreational activities or sports does the your child like to participate in?

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* 10. For school-aged children, what subject area does your child seem to have the most difficulty in at school?

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* 11. For school-aged children, does your child seem to have difficulty completing homework? 
If yes, explain why you think this is so.

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* 12. Does your child enjoy watching a tablet, phone, or television?

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* 13. How far away from the screen does your child sit?

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* 14. Is your child interested in playing with books or reading?

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* 15. What size of pictures or font do they enjoy reading?

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* 16. Does glare on pages or screens seem to affect your child?

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* 17. Do you notice your child bringing things close up to look at them?

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* 18. Does your child have trouble finding food or knowing what is on their plate?

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* 19. Do you ever notice your child turning their head to look at objects?

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* 20. If you answered yes to the previous question, which way do you notice their head tilt?

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* 21. Does your child get tired, angry, or frustrated after using their vision for extended periods of time (visual fatigue)?

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* 22. Is your child able to see things through the window outside while they're sitting inside the car?

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* 23. Is your child able to recognize you visually when you enter a room?

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* 24. Can your child recognize family members or close friends visually from across a room?

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* 25. Is your child able to perform activities of daily living at a level equal to other children their age?

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* 26. If you answered no, what kinds of daily living skills does your child find difficult?

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* 27. What kinds of activities/things does your child particularly enjoy?

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* 28. What activities/things does your child actively avoid or dislike?

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* 29. Is there anything else you would like us to know about your child before our assessment?

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* 30. Are there any questions that you would like us to answer before the assessment?

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