ADDITIONAL QUESTIONS WHICH MAY BE ASKED:

GLASSES:

1. Does the client need or wear glasses?
   • YES
   • NO
2. Last examination was within two years?
   • YES
   • NO

HEARING:

1. Does the client need or wear a hearing aid?
   • YES
   • NO

MEDICAL/PHYSICAL:

Has the client experienced any of the following:

1. multiple, chronic ear infections
   • YES
   • NO
2. multiple, chronic sinus problems
   • YES
   • NO
3. serious accidents resulting in head trauma
   • YES
   • NO
4. prolonged, high fevers
   • YES
   • NO
5. diabetes
   • YES
   • NO
6. severe allergies
   • YES
   • NO
7. frequent headaches
   • YES
   • NO
8. concussion or head injury
   • YES
   • NO
9. convulsions or seizures
   • YES
   • NO
10. long-term substance abuse problems
    • YES
    • NO
11. serious health problems
    • YES
    • NO

1. Is the client taking any medications that would affect the way he/she is functioning?
   • YES
   • NO

If yes, what is the client taking?

How often?

Referrals needed/made: