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Infant/Toddler Questionnaire

Please carefully completing our questionnaires. 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

Nutritional Information

Vision History

Have you or anyone else ever noticed any of the following happening with your child's eyes?

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.

Developmental History

Current Abilities/Behavior

Please list the age at which your child could do the following. If unable, mark as N/A.