Developmental Disabilities

Vision/Hearing » Vision

Vision/Hearing

Functional Vision Assessment Questionnaire

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Child’s Name:  _____________________________________    D.O.B.  ____________

 

Completed By: ______________________________________  Date:   _____________

 

Directions:  Please answer these questions as completely as possible.  Give as much detail as you can to each answer.

 

1.  How do you get the child’s attention – visually, auditorily, tactually?

 

2. Does the child have eye contact with people/objects?

 

3.  How does he explore new objects – visually, tactually?

 

4.  How far away does the child hold an object when examining it?

 

5.  At what angle relative to his eyes does he hold the object – directly in front, to the right, left, etc.?

 

6.  Can the child visually discriminate between objects and people?

 

7.  Can the child notice tiny objects (about the size of an M&M) placed in front of him?

 

8.  Does the child engage in any hand watching behavior?

 

9.  Does the child seek out or continually stare at light sources such as windows, lamps, fluorescent lights, ceiling lights, etc.?

 

10.  Does the child engage hands (play with objects, etc.) at midline?

 

11.  Will the child orient his body to visually follow an interesting object?

 

12.  Will the child reach for and attempt to grasp a visually stimulating object?

 

13.  Does the child reach quickly and accurately for the object?

 

14.  Does the child require tactile clues in Mobility and ADL tasks (eating, dressing, etc.)?

 

15.  Does the child use visual or tactile clues when doing fine motor tasks?

 

16.  If the child uses his vision to attend to objects, does he look directly at objects or does he turn head slightly to see?

 

17.  Can the child use scissors appropriately?

 

18.  Does the child use his vision when cutting with scissors or does he rely on tactile clues and templates?

 

19.  When catching or throwing a ball, does the child visually track the object path?

 

20.  Is the child able to negotiate stairs?  Does he alternate feet?  Does he hold onto a railing?

 

21.  Does the child use visual or tactile clues when matching/sorting objects?

 

22.  Can the child match colors?

 

23.  Can the child duplicate geometric designs drawn by instructor?

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