You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Social Media

Child Questionnaire

Please carefully complete our questionnaire. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your visual system related to your specific needs.

Please check one of the following:

General Information

Patient History

Vision History

Has your child complained about any of the following issues?

Contact Lens Policy: If you are requesting a contact lens prescription, our office provides a full service program – evaluation, fitting, and follow-up. Our office does not release the contact lens prescription until you have been successfully evaluated and fitted.

Family History

If anyone in the family (grandparents, uncles, aunts, cousins, mother, father, and/or siblings) has any of the following conditions, please indicate who. If not applicable, please leave it blank.

Nutritional Information

Developmental History

List the age at which your child could do the following. If unable, mark with N/A.

Television Viewing/Leisure Time Activities


Only complete this section if your child has starting schooling.

General Behavior

Family and Home

Lifestyle Checklist

Please assign a value between 0 and 4 for each symptom. 0 is Never or Non-existent, 1 is Occasionally, 2 is Often, 3 is Frequently, 4 is Always.