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Adult Amblyopia & Strabismus Questionnaire

  • Please fill out this questionnaire carefully. Please bring the completed form with you on the day of the evaluation. Thank you.
  • Medical History

  • Visual History

  • SelfFamily
    Eye Turn/Strabismus
    Lazy Eye/Amblyopia
    High Prescription
    Learning Disabilities
    Eye Shake/Nystagmus
    ADD/ADHD
  • Do you have double vision? If yes, please answer the questions below.
  • Work History

  • NeverSeldomFrequentlyAlways
    Double vision
    Blurred vision at near
    Head tilt or closing one eye when reading
    Headaches associated with near work
    Words run together when reading
    Falling asleep when reading
    Vision worse at the end of the day
    Poor ability to remember what is read
    Skipping words/lines when reading
    Avoiding sports and games
    Inability to estimate distances accurately
    Difficulty copying from chalkboard
    Holding reading material too close
  • A report will be written soon after the examination. Would you like our office to
x

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