Child Vision Symptoms Checklist

Contact Information

Please enter your contact information so I can respond back to you after you complete the symptoms checklist.

Email Address: *

Name: *

Child's Name: *

Appearance of Eyes

Check all that apply regarding the appearance of your child's eyes:

Reddened eyes of lids

Eyes tear often

Encrusted eyelids

Frequent styes on lids

Complaints

Click all that apply regarding the complaints your child has when they use their eyes:

Teacher's Observations

Click all observations made by you (if you home-school) or your child's teacher:

Dr. Paul Harris, Optometrist