Strabismus Evaluation Form
Use this form to provide the key details needed for a strabismus evaluation. Please complete all fields clearly and accurately.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Evaluation Details
Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Concern or Reason for Visit
*
Issue Pattern
*
Constant
Intermittent
Unsure
Symptoms and History
When did the eye alignment symptoms begin?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you experience double vision?
*
Yes
No
Unsure
Please describe any prior eye treatment or surgery.
Submit
Should be Empty: