Child Patient History

The following information will help Drs. Machmer and McAvoy in the assessment and diagnosis of your child's visual development and processing. Please answer to the best of your knowledge.

Do you have any concerns with their vision or motor skills? If so, please describe:

Please check any of the following conditions that they have been diagnosed with:

Other Conditions:

Please list any current medications:

Birth, Infancy, and Toddler Years

Were they born?
How were they delivered?
Were forceps used during delivery?
Any complications during pregnancy?
Any complications during birth?
Was an incubator or oxygen used?

When were the following milestones met:

Crawling
Walking
Speaking
Potty Trained

Motor Skills:

Can they do the following:

Stand/Hop on one foot
Catch a ball
Ride a bike
Have difficulty with balance
Struggle with hand-eye co-ordination
Right or left handed

School Aged (if applicable):

Do they:

Enjoy School
Enjoy reading
Enjoy being read to
Read at or above grade level
Comprehend what they read
Reach their potential in school
Print neatly
Reverse letters
Come home from school exhausted
Come home from school with headaches
Have any classroom adaptations

Do you and/or their teacher have any concerns with their school performance and/or behaviour?
If so, please describe:

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1:00pm - 5:00pm

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1:00pm - 5:00pm

Thursday

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4:00pm - 8:00pm

Friday

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1:00pm - 5:00pm

Closed Saturday, Sunday and Stat Holidays