All questions contained in this questionnaire are strictly confidential and will become part of the medical record.
RESPONSIBLE PERSON INFORMATION
Please list the names and ages of your immediate family:
List Illnesses, Bad Falls, High Fevers, etc.
Is there any history of the following? (please check)
Members of the family who have had visual
attention and the reason:
Does your child report any of the following:
Which Subjects Are:
FAMILY AND HOME
Please list all individuals who are able to pick up your child.
IF YOUR CHILD HAS A HISTORY OF EYE TURN/LAZY EYE/WANDERING EYE, PLEASE COMPLETE THE FOLLOWING SECTION, IF NOT
PLEASE SKIP TO THE NEXT SECTION.
(Check all that apply)
Do you notice the eye turns more when your child looks:
(include age started, duration, eye patched and results)
(include age when surgery was performed, # of operations, the eye operated on and results)
IF YOUR CHILD HAS A HISTORY OF HEAD INJURY, PLEASE COMPLETE THE FOLLOWING SECTION.
BRAIN INJURY HISTORY
SUBSEQUENT/OTHER PROFESSIONAL CARE
What types of professional care have you received or are you currently receiving? (check all that apply)