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DISCLAIMER

Please read the following carefully:

Mr. Shapiro is not a licensed optometrist or opthalmologist.  He does not diagnose or treat the presence of abnormal conditions of the eye and its appendages, or the accommodative and refractive conditions of the eye:  or prescribe visual training and/ or the use of scientific instruments to train the visual system, and is not licensed in the state of Colorado to do so.  You should consult with and follow the instructions of an optometrist or opthalmologist when using visual training procedures.

Part I  -  Preliminary Assessment Form

Important User Instructions:

Print this form first, complete all information,
and fax completed form to (719) 495-7137

Name: __________________________ Grade: ____Age: ____

Address: ______________________________________

City/State/Zip:__________________________________

Phone:________________Daytime Phone:____________

Parents Names: _________________________________

Developmental History:

Please provide a brief history of your child's developmental and medical history, citing any unusual difficulties, illnesses or experiences:

Does your child wear glasses?  Yes   No

When was your child's last eye exam, either by the school or a pediatrician?
                          

Do you know or suspect that your child has food, preservative or dye sensitivities? Any other helpful information concerning food and/or diet?                                         Yes   No

What educational difficulties is your child experiencing?

Please describe your child's learning process and educational background

When did you first notice school problems?

What has been done for these difficulties?

Have you been pleased with the progress your child has made with these programs?  Please explain.

                                      Yes   No

Are there other related problems, such as behavioral, social or disciplinary?

                                      Yes   No

Please explain, briefly, the nature of these other problems:

How does your child feel about his school performance?

Is your child's self-image low in regards to school achievement?

                                      Yes   No

Is he motivated to do school work?

                                      Yes   No

End of Preliminary Assessment Form Part 1

Please continue to the SYMPTOM PROFILE FORM: Part II:                                   click here.

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