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New Child Questionnaire

New Child Questionnaire

  • Home New Child Questionnaire

    Select Your Appointment Location*
    Personal Details
    Child’s Date of Birth*
    Medical History
    Has your child previously be assessed by any of the following?
    Developmental History
    Visual History
    Family History
    Observable behaviors possibly related to visual problems during home/school/outdoor environment
    Signs of Focusing Problems
    Signs of Tracking Problems
    Signs of Visual Processing
    Signs of unusual glare sensitivity
    Education History
    Is your child having difficulty with:
    How did you hear about us?
    Future communication