SECTION 1 – GENERAL STUDENT INFORMATION
1.
Student Name:
2.
Date of Birth:
3.
Parent(s) Interviewed:
4.
Report Date:
5.
Setting:
SECTION 2 – VISION/MEDICAL HISTORY (TVI should conduct a review of the records)
1.
Has your child had an ophthalmological exam? YES or NO a.
When:
2.
Who was the doctor? a.
Telephone: b.
Address:
3.
What caused your child’s impairment:
4.
Has your child had eye surgery? YES or NO a.
If so, for what?
5.
Has your child had a hearing exam? YES or NO
6.
Who was the audiologist? a.
Telephone: b.
Address:
7.
Does your child have other documented disabilities? YES or NO a.
Disability:
8.
Where could we access additional medical records if they are needed?
Parent Interview FVA-LMA including Preschool (Ages 3-5).docx Page 1 of 4

9.
What medications does your child take, and when are they administered?
10.
Is there a medical plan available at school? YES or NO
11.
Does your child have any medication restrictions? YES or NO a.
If yes, what are they:
12.
Does he/she have seizures? YES or NO a.
How often?
13.
Does anything in the environment (e.g., light, noise, etc.) seem to trigger seizure activity?
SECTION 3 – EDUCATION PROGRESS (TVI should conduct a review of the records)
1.
What was the last school that served your child?
2.
Who was the teacher? a.
Telephone: b.
Address:
3.
Was attendance an issue? YES or NO
4.
How are your child’s listening skills? a.
Explain:
5.
Has your child been enrolled in a program for students with visual impairments on any previous occasion? YES or NO
SECTION 4 – MOBILITY/TRAVEL
1.
Does your child ever have problems getting around in the dark? YES or NO a.
If so, explain:
2.
Does your child have problems with bright light? YES or NO a.
Explain:
3.
How does your child adjust to different lighting?
4.
Does your child have trouble getting around in unfamiliar environments? YES or NO:
5.
Does your child fall over things, or bump into things as he/she is walking? YES or NO a.
Explain:
Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998 by Heartland AEA 11 — Vision Department - 2003
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SECTION 5 – VISUAL RESPONSE
1.
Does your child watch television? YES or NO
2.
How far away from the screen does your child sit?
3.
Does your child like to play computer or video games? YES or NO
4.
How far away from the screen does your child sit?
5.
Does your child like to play with books or read? YES or NO
6.
What size pictures and font do they enjoy reading?
7.
Does the glare on a page seem to bother your child? YES or NO
8.
If your child has been diagnosed as being totally blind, do you think that he/she sees? YES or NO a.
Explain:
9.
Do you notice your child bringing things closer to look at them? YES or NO
10.
How close does your child generally hold small objects?
11.
Do you ever notice your child turning their head to look at objects? YES or NO a.
If yes, which way do they turn their head?
12.
Do you feel that there are areas of your daughter’s/son’s visual field, which are more effective than other areas? YES or NO a.
If so, explain:
13.
Do you ever notice your child looking at an object, and then looking away before reaching for the object? YES or NO
14.
Does your child stare at light? YES or NO
15.
Do you child’s eyes cross, wander, or not appear straight at any time? YES or NO a.
Explain:
SECTION 6 – ACTIVITIES OF DAILY LIVING
1.
Is your child able to perform activities of daily living at a level equal to other children their age?
YES or NO a.
If no, what activities give him/her the most trouble? i.
Personal body care ii.
Self-help
Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998 by Heartland AEA 11 — Vision Department - 2003
Parent Interview FVA-LMA including Preschool (Ages 3-5).docx Page 3 of 4

iii.
Social habits iv.
Home assistance v.
Recreational/leisure skills vi.
Moving in the near environment vii.
Other
SECTION 7 – SOCIAL
1.
Does your child have friends? YES or NO
SECTION 8 – PERSONALITY
1.
Are there activities that your child particularly enjoys?
2.
Are there activities that your child avoids?
3.
What sort of foods does your child like to eat?
4.
What smells seem to be pleasant for your child?
5.
Does your child interact with other child in about the same way as other children their age? YES or NO a.
Explain:
6.
How does your child communicate?
7.
What time of day is your child most alert?
8.
What things does your child look at most consistently?
9.
What things does your child like to listen to?
Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998 by Heartland AEA 11 — Vision Department - 2003
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