Forms and Surveys

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We would like to streamline your visit and enhance our services by gathering valuable insights about your eyes. Your answers will assist us in guiding you toward proactive measures for clear and healthy vision. By completing relevant forms and surveys, you are helping us improve your experience at Eyecare Kids.

Patient Information Forms

Please complete prior to your appointment with our optometrist.

Patient Form for Child

Complete our patient form to ensure your visit is seamless. Providing accurate information helps us tailor our services to your needs, ensuring you receive the best care possible.

Patient Form for Adults

Complete our patient form to ensure your visit is seamless. Providing accurate information helps us tailor our services to your needs, ensuring you receive the best care possible.


Please complete as required by your optometrist.

Brain Injury Vision Symptom Survey

Has your child had a recent head injury or trauma? The Brain Injury Vision Symptom Survey assesses visual symptoms experienced by individuals following a brain injury. These symptoms may include blurred vision, double vision, light sensitivity, and difficulty focusing or tracking objects. Your optometrist may recommend this survey to accurately diagnose and address visual issues in those with brain injuries, helping to improve quality of life and overall recovery process.

*Laukkanen H, Scheiman M, Hayes JR. Brain Injury Vision Symptom Survey (BIVSS) Questionnaire. Optom Vis Sci. 2017 Jan;94(1):43-50. doi: 10.1097/OPX.0000000000000940. PMID: 28027193.

Convergence Insufficiency Symptom Survey (CISS)*

Has your child been complaining of eye strain, double vision, or having reading difficulties? Convergence Insufficiency is an eye condition that affects how the eyes work when focusing on nearby objects. Your completed CISS will be reviewed by our optometrists, who will be able to make preliminary risk assessments of CI in your child. The Convergence Insufficiency Symptom Survey evaluates symptoms associated with convergence insufficiency, a condition where the eyes have difficulty working together at close distances. Individuals may experience eye strain, headaches, double vision and difficulty concentrating especially while reading or on the computer. Your optometrist may recommend this survey to assess the severity of symptoms and guide appropriate treatment strategies if you are suspected of having convergence insufficiency.

*Darko-Takyi C, Owusu-Ansah A, Boampong F, Morny EK, Hammond F, Ocansey S. Convergence insufficiency symptom survey (CISS) scores are predictive of severity and number of clinical signs of convergence insufficiency in young adult Africans. J Optom. 2022 Jul-Sep;15(3):228-237. doi: 10.1016/j.optom.2021.05.001. Epub 2021 Oct 18. PMID: 34674968; PMCID: PMC9237593.

Myopia Risk Survey

Curious about your child’s risk of myopia? Take our quick and informative myopia risk survey to gain insights into your child’s eye health and potential risk factors.

The Myopia Risk Survey assesses the likelihood of developing myopia in children. This survey includes questions about family history of myopia, outdoor activity levels, and reading habits. Your optometrist may recommend this survey to identify children at higher risk of myopia, allowing for proactive measures to prevent or manage the condition effectively.

Vision Screening Checklist

Have you ever considered whether your child might have an undetected vision problem? Since most children do not complain of a vision problem, your observations and responses will contribute to a more supportive and effective learning environment for your child.The Vision Screening checklist serves as a preliminary assessment for parents, guardians and educators to identify potential vision issues in children.

DVIP Questionnaire

Have you ever considered how your child’s vision impacts their overall development and learning abilities? The DVIP questionnaire evaluates your child’s developmental vision information processing. Your responses offer valuable insights into their vision-related development, guiding us toward the next steps in their vision care journey. Thank you for participating. 

The Developmental Vision Information Processing Questionnaire assesses various aspects of visual processing skills in children. It covers areas such as visual attention, visual memory, visual-motor integration, and visual perception. This questionnaire helps identify if potential visual processing deficits may be impacting your child’s performance in school and sports.

Ocular Surface Disease Index Survey (OSDI)*

Have you ever experienced discomfort in your eyes? This survey is designed to assess and quantify the symptoms of ocular surface diseases, such as dry eye syndrome, in adults. Your participation will provide valuable insights into your eye health and help in the evaluation of your ocular surface condition. Thank you for taking the time to complete this survey. 

The OSDI survey is a widely used questionnaire designed to evaluate the severity of symptoms related to ocular surface disease, such as dry eye syndrome. It includes questions about the frequency and severity of symptoms like dryness, irritation, and visual disturbances. Your Optometrist may recommend this survey to assess the impact of ocular surface disease on your quality of life and guide treatment decisions accordingly.

*Dougherty BE, Nichols JJ, Nichols KK. Rasch analysis of the Ocular Surface Disease Index (OSDI). Invest Ophthalmol Vis Sci. 2011 Nov 7;52(12):8630-5. doi: 10.1167/iovs.11-8027. PMID: 21948646; PMCID: PMC3230285.

Visual Snow Syndrome Checklist (VSS)*

Have you experienced seeing “static” across your visual field? Visual Snow Syndrome (VSS) is a neurological condition which should be diagnosed consistent with the accepted criteria, diagnosis by exclusion of other possible aetiologies. This checklist is a convenient aid to assessment, and should be saved to the patient record for clinical and medicolegal reasons. 

The Visual Snow Syndrome Survey assesses symptoms associated with visual snow syndrome, characterized by persistent visual disturbances such as seeing flickering or static-like visual noise. Your Optometrist may recommend this survey to better understand the nature and severity of your symptoms, aiding in diagnosis and treatment planning for visual snow syndrome.


Book a comprehensive eye test for your child today.

Danny the dragon

Book a comprehensive eye test for your child today.

Danny the dragon