Vision Screening And Eye Health Survey printable pdf download

LWS~KIDS Vision Screening and Eye Health Survey

Site Name:

Date:

Sent Home

Child’s Date of Birth: _____/____/________

(Month) (Day) (Year)

Please answer the following questions about your child’s health by circling Yes, No, or Unsure

Has either parent had a vision problem as a child—glasses, lazy eye, crossed eye,

Yes No

Unsure

patch?

Has either parent had trouble learning to read at school?

Yes No

Unsure

Was your child premature (born early) or did she/he stay in the hospital for more

Yes No

Unsure

than a week after birth?

If you have an older child, did he or she have trouble learning to read?

Yes No

Unsure

Do you think, or do others who spend time with your child think, that your child

Yes No

Unsure

has difficulty seeing toys, books, TV, or other things?

Do one or both of your child’s eyes look crossed, or not lined up, all the time or

Yes No

Unsure

sometimes?

Do one or both of your child’s eyelids droop or cover the eye even when it is ‘open’

Yes No

Unsure

or does your child “squint” an eye at times?

Does your child tilt his/her head a lot?

Yes No

Unsure

Does your child rub his/her eyes a lot?

Yes No

Unsure

Does your child have red, itchy, watery eyes often?

Yes No

Unsure

Has your child had his or her eyes checked with an eye chart with shapes or letters,

Yes No

Unsure

or with a hand held machine, by the doctor or at preschool?

Has your pediatrician ever referred your child for an eye examination with an eye

Yes No

Yes

doctor, (Optometrist or Ophthalmologist)?

Has anyone from your child’s Early Intervention, preschool or Springfield Public

Yes No

Unsure

Schools referred your child for eye examination by an Optometrist or

Ophthalmologist?

Has your child had an eye exam by an Optometrist or Ophthalmologist?

Yes No

Unsure

Have you been able to get the eye glasses/ vision services your child needs?

Yes No

Unsure

Who is your insurance provider? ________________________________________

Were you able to get the vision services for your child here in Springfield?

Yes No

Unsure

How long did it take to get the glasses/ vision services your child needed? Circle one:

2 Weeks

1 Month

3 Months

6 Months

9 Months

1 Year

Unsure

[Type text]

Vision Screening And Eye Health Survey

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