Teacher’s Observations – On Line Form Please ask your child's teacher to complete this form online and submit to us. By doing so, you accept and grant permission for this information to be shared with David J Neilson, Optometrist.Please enable JavaScript in your browser to complete this form.Date *DateTimeTeacher Name *FirstLastStudent Name *FirstLastParent Name *FirstLastClass *School *Does the Student complain of any of the following? *Headaches - when?Red, Sore or Watery EyesSeeing double, or the letters running/movingBlurry books and/or whiteboardAppear to be squinting to seeGets very close to workDifficulty maintaining attention to close work (avoids reading)Loses place frequently when reading or misses and skips wordsContinues to use finger to keep place (after 7 years)Slow or poor copy from the boardStill reverses letters or numbers (after 7 years)Appears clumsy or uncoordinatedThis is a checklist of symptoms, which have been found to be frequently associated with visual problems. We realise that not all these observations will apply to any one student. Teacher's observations of a student's behaviour are often the first indication that the child may be having visual problems. If your student/child suffers from any of these symptoms, we recommend they have an eye test.Does the child's performance decline with time spent at the task?Do you feel the child is performing to their potential?What subjects/abilities concern you most?Please give any comments, impressions, special help found effective or any other observations that you think are applicable for this student...Teacher's Signature (Please type name) *EmailSubmit
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