Parent Questionnaire©  |  Objective Vision Testing  |  Scoring Guidance©  |  Results & Next Steps©

Parent Questionnaire©

The vision screening process begins with caregivers completing the Parent Questionnaire©. It collects important information about the child's visual health, medical and family history, visual behaviors, and caregiver concerns to help identify possible vision concerns. It was developed with input from several Colorado experts, including pediatric ophthalmologists and optometrists.

The Parent Questionnaire© is available in English and Spanish through secure, HIPAA-compliant CognitoForms and as downloadable PDF forms.

Use of the 2025 Parent Questionnaire© is limited to professionals who have successfully completed the 2025 A Shared Vision training. Organizations wishing to copy, customize, or incorporate the Parent Questionnaire© into another form, platform, or workflow must obtain written permission from A Shared Vision.

Quick Links

• Parent Questionnaire© CognitoForms Links
• Parent Questionnaire© PDFs
  

Information Collected

• Contact Information: Captures basic identification details of the child and caregiver.
  
• Eye Doctor Examination: Inquires about previous eye exams, results, treatments, and follow-up visits.
• Family Vision History & Child’s Medical History: Collects data on genetic predispositions and medical issues that could influence vision.
• Appearance of Eyes and Eyelids: Checks for any visible abnormalities or symptoms that might indicate vision issues.
• Visual Behaviors: Explores how the child uses their vision in daily activities, with questions adjusted for different age ranges.
• Caregiver Concerns: Provides space for any additional concerns not previously covered.

Process

Before meeting with a family, ask the caregiver to complete the Parent Questionnaire© in English or Spanish. The 2025 Vision Screening Protocol© supports both CognitoForms and downloadable PDF forms. Use the workflow that best fits the family, your preferences, and your organization's procedures. To email a PDF or email or text the CognitoForms link, use one of the email and/or text templates.

Whenever possible, have the caregiver complete the Parent Questionnaire© before the visit so you have time to review their responses and focus the screening discussion on their observations and concerns.

Using CognitoForms

Upon completion, caregivers receive a PDF of their responses by email (figure 1). They may save the document and share it with their pediatric eye doctor for further evaluation, if appropriate. 
Vision screening professionals also receive a PDF with the caregiver's responses, as well as identification of vision concerns associated with the responses (figure 2).

Responses are stored securely on the HIPAA-compliant cloud-based platform.

If the Questionnaire Isn't Completed in Advance

Work with the caregiver to complete the Parent Questionnaire© before proceeding with the vision screening. Use either CognitoForms or the downloadable PDF, based on the workflow that best fits the family, your preferences, and your organization's procedures. Please do not omit questions, as each contributes to identifying possible vision concerns. Review the completed questionnaire using the Scoring Guidance©.

Figure 1: Parent Questionnaire with Caregiver's Responses (click to download PDF)

Figure 2: Parent Questionnaire Responses with Scoring Guidance (click to download PDF)