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DID YOU SEE THE NEW SIGNAGE?
Progressive Optometry has actually been a part of Browz Eyeware for a number of years. Nothing is changing aside from our sign! Hope to see you soon!

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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!
  • MM slash DD slash YYYY
  • 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

We are excited to announce that our McLeod Trail office has officially merged with our 130th ave location to provide our patients with extended hours, updated technology, and optimal care. Come visit us at our new home!

McLeod Trail & South Trail Crossing Merger

We are excited to announce that our McLeod Trail office has officially merged with our 130th ave location to provide our patients with extended hours, updated technology, and optimal care. Come visit us at our new home!