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Infant Pre-Screening Questionnaire

MM slash DD slash YYYY
Please rate the following signs and symptoms according to your current observations and/or your patient's current reports about how his/her eyes feel. Indicate the frequency of these signs and symptoms using the following number scale:
Score 0 for Never, 1 for Infrequently, 2 for Sometimes, 3 for Fairly Often, 4 for Always
Frequent tilting of the head(Required)
Frequent rubbing of the eyes(Required)
Squinting when looking at objects(Required)
Holding objects close to their nose to view(Required)
Closing one eye to look at something(Required)
Turning of an eye in, out, up or down(Required)
Poor eye hand coordination or not grasping accurately(Required)
Avoidance of table top work such as coloring, puzzles, other detailed activities(Required)
Poor eye contact(Required)
Not responding to parent facial expressions(Required)
**Total scores greater than or equal to 13 warrant a consultation with a Developmental Optometrist specializing in the diagnosis and treatment of Vision-Related Learning Problems.