Welcome

There are 3 Sections to complete:

1) Background History

2) Visual History

3) Visual Difficulties (VDQ)

Please complete all sections with as much information as possible.

Background History Questionnaire Pre- 16

The aim of this questionnaire is to gain a brief overview of your child’s background, as well as your reasons for requesting an assessment.

Any areas of concern will be discussed in more detail at the start of the assessment.

Parent Details

Parent First Name *

Parent Last Name *

Phone

Email *

Address

Street Address

City

Post Code

Child Details

Child First Name *

Child Surname *

Birthday Date *

Age *

Year Group *

Parent Details

Relationship To Child *

Brief Reason For Requesting Assessment. *

How Is Your Child Impacted By Their Current Difficulties? *

Health and Developmental History

1. Was your child born prematurely or did they experience any difficulties during or shortly after birth?

2. Did your child reach all milestones at the expected age?

3. Has your child ever attended speech or language therapy?

4. Is spoken language an area of strength for them?

5. Does your child have difficulties with pronouncing words, finding the correct words or articulating their thoughts?

6. Has your child had any issues with hearing, and at what age? (Includes re-occurring ear infections, glue ear and grommets.)

7. Date of last eye test and result. A recent eye test is required before we carry out an assessment.

8. Has your child had any issues with their eyes or vision, and at what age?

9. Does your child experience difficulties with fine or gross motor-skills?

10. Does your child have any medical or mental health conditions and are they taking any medication? *

* Please indicate if you give permission for this to be included in your child’s report.

Yes

11. Has your child ever experienced a significant head injury?

Familial History of SpLDs or other Developmental Conditions

1. Do any family members have difficulties with literacy?

Linguistic History

1. Is English your child’s first language?

Yes

Educational History

1. Has your child had any significant or reoccurring periods of absences from school?

2. Does your child currently receive any additional support at school?

3. Has your child ever had an EHCP or Statement of SEN?

4. Has your child ever had any previous assessments for dyslexia or other issues?

Please use the space below for any additional information:

Additional Info:

Visual History Questionnaire

The following questions provide information on visual history, which helps in putting any reports of current visual difficulties into context.

1. Have you been prescribed and advised to wear any optical prescription lenses (i.e. glasses or contact lenses)?

Yes

1a. Are these required for distance vision (e.g. television), near vision (e.g. reading), or both?

1b. Do you wear your glasses / contact lenses as advised?

If correction prescribed and normally worn for near work, then it should be worn for SpLD assessment

1c. Do you have your glasses / contact lenses with you today?

2. How long ago was your last sight test or eye test by an optometrist (‘optician’) — less than two years ago, more than two years, or NEVER?

Less than 2 years

More than 2 years

Never

3. Have you ever used coloured overlays or precision-tinted lenses?

Yes

3a. Who recommended and provided these?

3b. Why were they recommended?

3c. Did they help? — if YES, in what way?

3d. Do you still use them? — if NO, why not?

4. Have you ever had hospital treatment for a problem with your eyes or vision?

Yes

For example:

wearing a patch for a ‘lazy eye’ (amblyopia) or,
wearing glasses or having exercises to help correct a ‘turn’ in your eye (squint),
or any other condition.

Details:

Visual Difficulties Questionnaire

The VDQ request simple yes/no answers to a few questions about symptoms and signs involving:

FEEL (visual discomfort, Q1-3)
SEE (visual disturbance Q4-7)
DO (behaviour Q8-9)
One general question (10) about any other experience.

Note the emphasis on the word 'often' in questions 1-9, which is deliberately intended to identify when a symptom occurs frequently.

Therefore, the individual should be advised to answer NO if reported symptoms would be considered infrequent (e.g. rarely, occasionally, sometimes, <2-3 times per month).

Please tick to indicate you have read & understood these notes.

Yes

FEEL (visual discomfort)

1. Do you often get headaches when you read or study?

2. Do your eyes often feel sore, or gritty, or watery?

3. Does reading from white paper or from a bright screen often feel uncomfortable?

SEE (Visual Disturbance)

4. Does print often appear blurred, or go in and out of focus, when you are reading?

5. Does the print, or book, or screen, often appear double when you are reading?

6. Do words often seem to move or merge together when you are reading?

7. Do objects in the distance often appear more blurred after you have been reading?

DO (behaviour)

8. Do you often have to screw up your eyes to see more clearly when you are reading?

9. Do you often move your eyes around or blink to make things clearer or more comfortable when you are reading?