Interview Form – Parent of a Student with CVI



1.  What is the cause of your child’s visual impairment, as you understand it?



2.  What surgeries has your child had?



3.  What medications does your child currently take and what side effects do you notice as a result of these medications?



4.  When was your child’s last visit to the ophthalmologist or optometrist?  Does your child wear glasses?



5.  Does your child have any additional handicapping conditions?  Does your child have any difficulties with hearing?



6.  What are your concerns about your child’s vision?



7.  Does your child have a favorite toy or object that he/she most often responds to?  Describe it for me.  Does your child have a favorite color or does your child seem to have no color or pattern preference?



8.  Do you notice that your child is more visually attracted to toys/objects that are still or have movement?    For example, does your child visually attend to moving ceiling fans or toys that have movement properties more than you would expect?



9.  Does your child ever have a delay in visual attending of a few seconds (or even up to 30 or 60 seconds)?



10.  Do you notice that your child more often visually alerts to objects/toys when presented on one side more than the other?   Does your child tilt or turn his/her head when visually observing a target?



11.  Do you notice your child using his/her vision more in a room that is quiet, with no auditory distractions?


12.  Will your child visually attend to your face and if so, how far away are you from your child?



13.  Will your child observe picture books and if so, describe what the pictures look like in their favorite book.



14.  Is your child attracted to lights or sunny windows?  Describe the setting/lighting if so.  How far away are the lights/window, what color are the lights, and can your child’s attention be redirected after he/she has been looking at lights/windows?



15.  Does your child demonstrate attending behavior when people first enter a room without making any sound?  If so, how far away are they when your child demonstrates recognition or alerts to their presence?



16.  When your child drops something, does he/she try to locate it and if so, how does your child do this?



17.  Do you notice your child visually attending to objects or people at a distance of greater than 10 feet when there is no sound to alert them?



18.  If given an unfamiliar toy, would your child respond to it or would he/she only respond to familiar toys/targets?



19.  Are there any other concerns you have with regard to your child’s vision that we have not discussed?  Are there any specific settings that you would like me to see your child in?



Created By Diane Sheline, CTVI, CLVT


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