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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?

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