Infant/Toddler 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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Patient History

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Are immunizations up to date?
Were there any reactions to immunizations?
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Is your child generally healthy?
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Are there any chronic problems like ear infections, asthma, or food or drug allergies?
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Is your child especially afraid of doctors?
What is your child's dominant hand?
Has guidance been given in use of hand?
Has a neurological evaluation been performed?
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Has a psychological evaluation been performed?
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Has a speech and language evaluation been performed?
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Has an occupational therapy evaluation been performed?
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Nutritional Information

How is your child's current diet?
Does your child like or crave sweets?
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Are there periods of very high energy?
Are there periods of very low energy?
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Vision History

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

Eyes Turn In or Out
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Frequent Eye Rubbing
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Eyes Watering
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Frequent Blinking
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Swelling around the eyes
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White appearance in pupil
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Eyes are frequently reddened
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Turns head to use only one eye
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Squints while looking at objects
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Poor large motor coordination
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Poor fine motor coordination
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Chronic Infection of Eye or Lid
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Has your child's vision been previously evaluated?
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Which was prescribed last eye exam?
Are the prescribed optical devices used?
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Does your child verbalize any complaints about his/her eyes or vision?
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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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Developmental History

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Did the mother experience any health problems during pregnancy?
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Were there any complications before, during, or immediately following delivery?
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Were forceps used?
Was oxygen used?
Were there every any concern over your child's general growth or development?
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Current Abilities/Behavior

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

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How is your child performing as compared to others his/her age?
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Was early speech clear to others?
Is speech clear now?
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Check the appropriate boxes if you have any concerns about the following behaviors:
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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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