Infant Pre-Screening Questionnaire Date MM slash DD slash YYYY Child's NameProfessional's NamePlease 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 Legend: N= Never , I= Infrequently , S= Sometimes , FO= Fairly Often , A= AlwaysFrequent tilting of the head* N I S FO A Frequent rubbing of the eyes* N I S FO A Squinting when looking at objects* N I S FO A Holding objects close to their nose to view* N I S FO A Closing one eye to look at something* N I S FO A Turning of an eye in, out, up or down* N I S FO A Poor eye hand coordination or not grasping accurately* N I S FO A Avoidance of table top work such as coloring, puzzles, other detailed activities* N I S FO A Poor eye contact* N I S FO A Not responding to parent facial expressions* N I S FO A Sub TotalsTotal Score**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. PhoneThis field is for validation purposes and should be left unchanged.
