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Home » Child Amblyopia & Strabismus Questionnaire

Child Amblyopia & Strabismus Questionnaire

Child Amblyopia & Strabismus Questionnaire

  • Please fill out this questionnaire carefully. Thank you!
  • Date Format: MM slash DD slash YYYY
  • Please indicate which location your appointment is booked at / or which location you would like your appointment scheduled
  • MEDICAL HISTORY

  • ChildFamily
    Eye Turn(Strabismus)
    Lazy Eye(Amblyopia)
    High Prescription
    Learning Disabilities
    Eye Shake(Nystagmus)
    ADD/ADHD
    Autism
  • DEVELOPMENTAL HISTORY

  • Age when child first:
  • Sit
  • Crawl
  • Walk
  • Talk
  • VISUAL HISTORY

  • If your child has worn an eye patch
  • EYE TURN HISTORY

  • 0 = symptom not present1 = symptom minimally present2 = symptom moderately present3 = symptom severely present
    Bumping into objects/clumsy
    Avoidance/poor focus with near work/reading
    Headaches around the eyes/forehead
    Head turn or tilt when looking at something
    Holding reading material too close
    Skipping of words when reading
    Trouble catching a ball
    Slow at copying from the board at school