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Supplemental Strabismus Questionnaire

This form is to be filled out in addition to a general adult or child questionnaire which can be found under the new patient forms tab. Please fill out the questionnaire carefully and as thoroughly as possible.

General Information

Medical History

Nutritional Information

Visual History

Previous Treatments

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. If this was completed in a previous child questionnaire, please continue to the end and submit this questionnaire.