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Vision Therapy Assessment Questionnaire

Once you have made your appointment, you will be asked to complete a questionnaire so that when you arrive we already have all the information to give you the best experience possible.

You have 2 options in getting the information to us:

  1. Download the PDF by clicking here, printing it off and completing it. Once done just send it to us by fax (01749 345074) or  bypost
  2. Complete the same questionnaire using our online form below. Although it seems very long, it will only take a few minutes to complete.

Please Note: All information you provide us, whether in digital or hardcopy form, is dealt with in the strictest of confidences

1. General Information

Appointment Time & Date:

2.  Visual Signs







3. General Signs



4. Developmental History

Did birth involve :
At what age did your child :

5. Hearing

6. Health

7. Family History

8. Laterality

Hand dominance in the family:
Is there similar confusion in the family?

9. School

*** If Yes, please could you let us see a copy of any reports that have been prepared ***
In your opinion, what are your child's:
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Christopher Young Opticians
46 High Street,
Shepton Mallet,
Somerset BA4 5AS

T:01749 345259
F: 01749 345074
smile@cyoungopticians.co.uk

Opening Times
Monday
9.00am to 5.30pm

Tuesday
9.00am to 5.30pm

Wednesday
9.00am to 5.30pm

Thursday
10.00am to 5.30pm

Friday
9.00am to 5.30pm

Saturday
9.00am to 1.00pm

Sunday
Closed

© 2016 - 2018 Christopher Young Opticians All Rights Reserved.