Teacher Questionnaire

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Teacher Questionnaire

Home Teacher Questionnaire

Select Your Appointment Location*

Carrum DownsLangwarrinMornington

Personal Details*

Student Date of birth

Vision One Eyecare will handle all personal information in accordance with the Privacy Act.

Observable Behaviours possibly related to visual problems during home/school / outdoor environment.

Covers or closes eye when readingComplains of words moving on the pageComplains of headachesComplains of double visionComplains of eye strainInattentive / day dreamsPoor reading comprehensionLoses paces when reading

Signs of Focusing Problems

Complains of blurred vision when readingComplains of blurred vision looking from desk to boardBecomes fatigued when readingAvoids small printsComplains from copying from boardRubs their eyes when concentratingShort attention when readingHolds the book’s or any electrical devices close

Signs of Tracking Problems

Loses place oftenSkips wordsAnd lines oftenUses finger to keep placeShort attention span when reading

Signs of Visual Processing

Slow to learn letter / sound correspondenceSlow copying from board to book, takes many looksDoesn’t recognize the same word repeated on a pagePoor recall of visually presented materialTrouble with spelling and sight words vocabularySlow copying and completing worksheetsUntidy writingReverses letters numbersMistakes words with similar beginningsCan respond orally but not in writingErases excessivelyTrouble learning Maths and basic concepts of size.

Education History

Is school work?

AverageBetter than averageBelow averageHas your student’s school progress been as expected for ability?

Is your student having difficulty with:

ReadingWritingSpellingMaths

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