VISION AND HEARING SCREENING QUESTIONNAIRE TO BE FILLED OUT BY THE PARENT OR GUARDIAN
Florida Diagnostic & Learning Resources System
Please select your Child Find Specialist or Evaluator before proceeding
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Tracy Sieber
Danielle Ingram
Carrie Lawson
Heather McCabe
Rebecca Skinner
Kristin Vangoeye
Henry Schmitges
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Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
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Male
Female
DateTime
Name of person completing this questionaire
First Name
Last Name
VISUAL CONSIDERATIONS:
1. Can the child follow with his/her eyes a moving target held about ten or twelve inches in front of him/her?
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Yes
No
2. When following a moving target with his/her eyes, can he/she easily move his/her eyes past his/her body midline?
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Yes
No
3. Does the child rub his/her yes frequently except for when tired ?
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Yes
No
4. Does the child turn his/her head to favor one eye when looking at something
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Yes
No
5. Does the child frequently hold things very close to his/her face to see them
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Yes
No
6. Are you concerned with his/her vision?
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Yes
No
What are your concerns with your child's vision?
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HEARING CONSIDERATIONS:
1. When asking your child to perform a task, does he/she appear to hear you even if he/she are not already looking at
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Yes
No
2. Does he/she react to loud or unexpected loud noises? (flinch? Or Cover his/her ears?)
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Yes
No
3. Does the child notice and/or imitate environmental sounds, such as a dog barking or a plane overhead?
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Yes
No
4. Is there a medical history of infections, tubes, wax buildup etc. ?
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Yes
No
5. Are you concerned with his/her hearing ?
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Yes
No
What are your concerns with your child's hearing?
Person Completing Form Signature
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