Children’s Vision Screening Survey Form
Please complete this survey to help us understand your child’s vision needs. This form does not collect sensitive or medical information.
Child’s First Name
*
Child’s Age
*
Grade Level
*
Please Select
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
Does your child wear glasses or contact lenses?
*
Yes, glasses
Yes, contact lenses
No
Not sure
How often does your child complain about difficulty seeing the board or reading up close?
*
Never
Rarely
Sometimes
Often
Always
Does your child frequently squint, tilt their head, or cover one eye when looking at things?
*
Yes
No
Not sure
Please rate how often your child rubs their eyes or blinks excessively.
*
1
2
3
4
5
How often does your child complain of headaches or tired eyes after reading or screen time?
*
Never
Rarely
Sometimes
Often
Always
Has your child had a vision screening at school or with a professional in the past year?
*
Yes, at school
Yes, with a professional
No
Not sure
Is there anything else you’d like to share about your child’s vision or eye habits?
Submit Survey
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