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Pediatric Vision Information Form

 

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready and completed for you when you arrive. If you have not scheduled your appointment yet, you may use our online appointment request form or give us a call. Required fields are marked with asterisks (*).

 

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Personal Information

Clinic Location: *

ABQ-North Valley - 6601 4th Street
ABQ-Northeast Heights - 9204 Menaul Blvd.
ABQ-Westside - 1646 Alameda Blvd.
Los Alamos - 800 Trinity Drive

Name (Last, First, MI): *

Date of Birth: *

Phone Number:

Email Address: *

 

Visual History

Does your child currently experience any of the following visual symptoms or performance problems?

Eyestrain

Yes No

Explain:

 

Headaches

Yes No

Explain:

 

Short reading span

Yes No

Explain:

 

Jerky eye movements

Yes No

Explain:

 

Loss of place reading

Yes No

Explain:

 

Loss of concentration

Yes No

Explain:

 

Poor achievement

Yes No

Explain:

 

Poor eye-hand coordination

Yes No

Explain:

 

Misread words

Yes No

Explain:

 

Reads close

Yes No

Explain:

 

Skips lines

Yes No

Explain:

 

Covers one eye reading

Yes No

Explain:

 

Letter reversals

Yes No

Explain:

 

Head tilt

Yes No

Explain:

 

Color difficulties

Yes No

Explain:

 

Poor posture

Yes No

Explain:

 

Poor depth perception

Yes No

Explain:

 

Bumps into objects

Yes No

Explain:

 

Squinting

Yes No

Explain:

 

Night blindness

Yes No

Explain:

 

Double vision

Yes No

Explain:

 

 

Please list any other concerns you have about your child's vision or eye health.

 
 

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1646 Alameda NW, Albuquerque, NM  |  800 Trinity Drive, Suite J-2, Los Alamos, NM