Please list the names and birth dates of your family:
RESPONSIBLE PERSON INFORMATION
Is there any Family history of the following?
Are there periods of
Does your child report any of the following? (If yes, when?)
HAVE YOU OR ANYONE ELSE EVER NOTICED THE FOLLOWING ( If yes, when?)
TELEVISION VIEWING/LEISURE TIME ACTIVITIES
Age at time of entrance to
FAMILY AND HOME
RELEASE OF INFORMATION AND INSURANCE FILING
Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us perform a more comprehensive evaluation of your child and to better meet your child’s specific visual needs.
If you have any questions on concerns that we may answer prior to your appointment, please do not hesitate to contact us.
You may leave a message for us 24 hours a day /7 days a week. We request a minimum of 24 hours notice if you are unable to keep this appointment.
Please be on time for your examination, so that we will have the maximum opportunity to evaluate your child’s visual status.
DR. JARED PEARSON, O.D.