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InfantSEE Patient History Form

  • Assessment Date:
    Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Eye History

  • (please check any that apply)
  • Developmental and Health History

  • PREGNANCY

  • in weeks

  • DELIVERY

  • (if known)

  • MEDICAL

  • IllnessAge at the timeWas the illness mild, moderate or severe? 
  • Accident/InjuryAge at the time 
  • Family History

  • RelationType of Problem 

  • I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of my child’s eyes and vision.
    I understand that the InfantSEE™ vision assessment is without charge. If further services or treatments are recommended, I may choose any eye care professional to provide those services.
  • Date Format: MM slash DD slash YYYY

  • Thank you for carefully completing this confidential questionnaire. This information will allow for a more efficient use of examination time and will contribute to the understanding of infant eye and vision development.