Adult and Childrens Opticians
Cardiff Est. 1989

02920 228 144

childopt@aol.com
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Under 16’s Home Questionnaire

Visual skills develop in conjunction with other sensory motor functions, such as movement and speech, and may be affected by pre and postnatal development, early illness and hereditary traits. The purpose of this questionnaire is to give the optometrist a more complete picture of any early history that may be relevant to the normal development of functional visual skills. This helps to establish time of onset and contributory factors involved in any visual abnormality.

Please fill in this questionnaire as fully as possible. It is particularly important that we know in advance if your child has significant language, learning or concentration difficulties or has been diagnosed with any specific condition, such as Autism.

Please ensure that all questionnaires are completed at least 2 weeks in advance of the appointment date. Without them a full examination may not be possible in the allocated time.

If you have any queries concerning this questionnaire, or you need a print version, please contact us.

Questionnaire

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