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

Parent Questionnaire©

The vision screening process begins with caregivers completing the Parent Questionnaire©. Leveraging a HIPAA-compliant multiplatform tool, the Parent Questionnaire© streamlines the collection of vital information from caregivers about their children's visual health to facilitate early detection of potential vision issues. It was developed with input from several Colorado experts, including pediatric ophthalmologists and optometrists.

Quick Links

• Parent Questionnaire© CognitoForms Links
  

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

To begin the vision screening process, send the caregiver a link to the Parent Questionnaire©, available in English or Spanish. 

Caregivers may open the link on any device (cell phone, tablet, computer), which automatically optimizes for user-friendly navigation and easy data entry.

Upon completion, caregivers receive a PDF of their responses via 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).

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

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

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

No Internet

If a caregiver has not filled out the Parent Questionnaire© prior to a vision screening meeting AND internet access is unavailable, you can use a printed copy of the Scoring Guidance© PDF to interview and document a caregiver’s responses. Please do NOT omit any of the questions as they are all essential in identifying possible vision concerns.