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Home » Eye Care Services » Adult Amblyopia & Strabismus Questionnaire

Adult Amblyopia & Strabismus Questionnaire

  • Please fill out this questionnaire carefully. Thank you.
  • Date Format: MM slash DD slash YYYY
  • MEDICAL HISTORY

  • SelfFamily
    Eye Turn/Strabismus
    Macula degeneration
    Reading disabilities
    Lazy Eye/Amblyopia
    Dry/Red Eyes
    Glaucoma
    Diabetes
  • VISUAL HISTORY

  • If you wear glasses, please answer the questions below.
  • Past eye surgeries?
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • If you have double vision, please answer the questions below.
  • Brain Injury Vision Symptom Survey

    Symptom Survey