DVIP Questionnaire - Total Optical

Total Optical

Developmental Vision Information Processing and Neuro-Developmental Assessment Questionnaire

Child's Name(Required)

First Last

Date(Required)

Form Completed by(Required)

First Last

Current Grade(Required)

Has a neuro divergent diagnosis been identified previously? ( ie. Dyslexia, Dyspraxia, ADHD, ADD, etc)

Diagnosed by: Dr

Date of Diagnosis

What investigations/interventions has child received in the past?

List prescribed medication/s and reason for medication:

Pregnancy/Birth History

Any known medical problems during pregnancy with child? (ie High blood pressure, diabetes, excessive vomiting, severe viral infection etc)(Required)

If yes, please give brief description(Required)

Was mother under severe emotional distress at any time during the first 12 weeks of pregnancy?

Was child born(Required)

At term

Early for term

Late for term

Was patient born vaginally or by caesarean section?(Required)

At birth, was there anything unusual or remarkable noted? ie skull distortion, heavy bruising, blue colour/skin tone, heavily jaundiced or required intensive care?(Required)

If yes, please explain(Required)

Was eye contact made between mother and baby within the first few minutes of life?(Required)

Ear, Nose and Throat

Does your child experience any of the following?(Required)

Does your child experience Asthma?(Required)

Infection induced asthma

Dust induced asthma

Mould induced asthma

Animal induced asthma

Food induced asthma

Do you suspect that your child has problems processing auditory information?(Required)

Has your child ever been investigated specifically for hearing disabilities?(Required)

Does your child forget spoken directions quickly?(Required)

Does your child get distracted by sounds?(Required)

Is your child oversensitive to sounds?(Required)

Does your child misinterpret conversations?(Required)

Does your child confuse similar sounding words?(Required)

Does your child need things to be repeated often?(Required)

Does your child have difficulty following sequential instructions?(Required)

Has your child received any auditory training?(Required)

If yes, which program?(Required)

Did the program include bone conduction?(Required)

Does your child have any of the following?(Required)

Hesitant speech

Flat and monotonous voice

Weak vocabulary

Poor sentence structure

Inability to sing in tune

General Information

Does your child have difficulty falling asleep at night?(Required)

Does your child have difficulty staying asleep at night?(Required)

Is your child apprehensive about trying new activities, visiting new places?(Required)

Is your child reluctant to try new foods?(Required)

Does your child like to chew on things (such as their t-shirt/pencils etc)?(Required)

Is your child clumsy/have frequent accidents?(Required)

Other concerns or observations: (eg bullying, emotional distress, death in the family, history of abuse etc)

Parents – Please note: During the assessment today, you may be tempted to assist your child in performing certain tasks. Please refrain from guiding or assisting as we are trying to assess what your child is capable of doing unaided and also observing their reactions. Thank you

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Developmental Vision Information Processing – Questionnaire

Total Optical

Pregnancy/Birth History

Ear, Nose and Throat

General Information

Parents – Please note: During the assessment today, you may be tempted to assist your child in performing certain tasks. Please refrain from guiding or assisting as we are trying to assess what your child is capable of doing unaided and also observing their reactions. Thank you