Child Online Questionnaire

Please carefully complete our questionnaire. This form does not need to be printed, once submitted, we should receive it on our end. 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. 

48 Hour Cancellation Policy

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill other patient’s scheduling needs and keeps the clinic operating at is most efficient level. Due to our 60-minute exams missed appointments are a significant inconvenience to your doctor, the clinic and other patients.

This policy is in place out of respect for our doctors and our clients. Cancellations with less than 48 hours notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot and leave a 60-minute hole in the doctor’s schedule.

  • Please provide our office with 48-hour notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 48-hour notice to change a scheduled appointment will be responsible for a $75.00 service chargeThis charge cannot be billed to insurance and must be paid before scheduling your next appointment.
  • We reserve your one-hour appointment time just for you. We do not double-book our patients so that we may provide optimum treatment outcomes for all our patients. 48-hour notice allows us to offer that time to a wait-listed patient.

NOTE: You will never be charged for a cancellation if it is made more than 48 hours in advance of your scheduled appointment time.

Thank you for providing our office and our patients with this courtesy.

Sincerely,

Drs. Garbus & Benosa, and the Family Vision Care Staff

Please check one of the following:

Appointment with:
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General Information

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Gender
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Is your child especially afraid of doctors?
Child's dominant hand
Has guidance been given in use of hand?

Patient History

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Has your child experienced any reactions to immunizations?
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Are there any chronic problems like ear infections, asthma, hay fever, or allergies?
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Has a neurological evaluation been performed?
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Has as psychological evaluation been performed?
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Has an occupational therapy evaluation been performed?
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Vision History

Has your child complained about any of the following issues?

Loss of Vision
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Blurred Vision
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Distorted Vision/Halos
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Loss of Side Vision
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Dryness
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Mucous Discharge
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Redness
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Sandy or Gritty Feeling
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Itching
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Burning
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Excess Tearing/Watering
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Glare/Light Sensitivity
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Eye Pain or Soreness
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Chronic Infection of Eye or Lid
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Sties or Chalazion
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Flashes/Floaters in Vision
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Tired Eyes
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Has your child's vision been previously evaluated?
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Which was prescribed last eye exam?
Are these optical devices being used?
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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.

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Nutritional Information

Current Diet
Does your child like or crave sweets?
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Is your child active?
Moderately or extremely active?
Are there periods of very high energy?
Are there periods of very low energy?
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Developmental History

Full-term pregnancy?
Did the mother experience any health problems during the pregnancy?
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Were there any complications before, during, or immediately after delivery?
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Were forceps used?
Was there ever any reason for concern over your child's general development?
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Was early speech clear to others?
Is speech clear now?

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

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Television Viewing/Leisure Time Activities

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Does your child watch TV?
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Are there any activities your child would like to participate in, but does not?
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School

Only complete this section if your child has starting schooling.

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Does your child like school?
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Has your child changed schools often?
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Has a grade been repeated?
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Does your child seem to be under tension or pressure when doing school work?
Has your child had any special tutoring, therapy, and/or remedial assistance?
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Does your child like to read?
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Are there any behavior problems at school?
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Your child's overall school work is:
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Does your child need to spend a lot of time/effort to maintain this level of performance?
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Do you feel your child is achieving up to potential?
Does your child's teacher(s) feel your child is achieving up to potential?

General Behavior

Are there behavior problems at home?
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Does your child say and/or do things impulsively?
Is your child in constant motion?
Can your child sit still for long periods of time?

Family and Home

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Does your child spend time with any other person, not in the home?
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Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)?
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Does you child seem to have adjusted?
Was counseling/therapy undertaken?
If yes, is it on-going?
Is family life stable at this time?
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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.

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Photos/Dilation Consent
48 Hour Cancellation Policy

Please do not submit any Protected Health Information (PHI).

Hours of Operation

Monday  

9:00 am - 6:00 pm

Tuesday  

9:00 am - 6:00 pm

Wednesday  

9:00 am - 6:00 pm

Thursday  

9:00 am - 6:00 pm

Friday  

9:00 am - 6:00 pm

Saturday  

Closed

Sunday  

Closed

Location

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