How to Administer in Clinic

• Give the questionnaire to each caregiver at check-in. Use the one-page document, provide a tablet with the questions, or text a link to the questions for the caregiver to complete on their cell phone.
• Review responses prior to the doctor, PA, or nurse conducting the well-child visit
• Score using the simple rules below.
  
• Document the results and plan in the chart/EHR.
  

How to Score the 17 Questions

Scoring takes less than 30 seconds:

• If any of Questions 1–5 are checked “Yes” → Refer.
  
• If two or more “Yes” responses appear anywhere on the form → Refer.
  
• If only zero or one “Yes” outside Questions 1–5 → monitor and rescreen at the next visit.
  

Positive items reflect caregiver observations of behaviors consistent with possible brain-based visual impairment.

How to Talk With Families

Use supportive, clear language:

• “Your answers show some visual behaviors that we want a specialist to look at more closely.”
• “This does not mean your child has a diagnosis. It means a pediatric eye doctor can help us understand more.”
• “We’ll set up a non-urgent referral to a pediatric ophthalmologist.”

Referral Recommendations

Type: Non-urgent referral to a pediatric ophthalmologist.
Timing: Within 4–5 weeks, if possible.
Where: See the [list of pediatric ophthalmologists] available on this site.
What to send:

• The completed questionnaire
• Your exam note and any other screening results
• Relevant developmental or therapy notes, if available
  

Documentation Checklist

• Attach the completed questionnaire to the chart.
  
• Record the scoring outcome.
• Document referral placed (non-urgent to pediatric ophthalmology, 4–5 weeks).
• Set recall or tracking reminders to confirm appointment completion.

Practical Workflow Tips

• Keep printed copies of the questionnaire at check-in.
• Create an EHR smart phrase for scoring and referral notes.
  
• Train your intake team to provide the questionnaire via paper, tablet, or link to a caregiver's cell phone.
• Flag referral-eligible results with a quick review of the caregiver's responses.
  
• Track referral completion rates to monitor effectiveness.

What Pediatric Eye Doctors Will Receive

When you refer using this Visual Behaviors Questionnaire©, eye doctors will see:

• The caregiver-completed questionnaire
• Your note with the reason for referral
• Any relevant developmental information you provide

This context helps specialists prepare for a thorough evaluation.

Training, Resources, Support

• Overview video (above)
• Sample Visual Behaviors Questionnaire© (view or download for professional review)
  
• Sample Results & Next Steps form (view or download for professional review)
  
• List of Pediatric Ophthalmologists [link]
  
• Quick-start one-pager for staff teams [link]

We provide:

• Onboarding calls for practice teams
• EHR templates for scoring and referrals
• Staff training slides
• Office-friendly print packs

Contact us at [email protected]

Frequently Asked Questions

Is the questionnaire diagnostic?
No. It highlights visual behaviors that support referral for further evaluation.

What if I am unsure after scoring?
When in doubt, encourage the family to schedule an appoint with a pediatric eye doctor in 4–8 weeks.

Does a normal instrument-based screening rule this out?
No. Device-based screening does not capture brain-based visual impairment. Instrument screening only evaluates a child's eyes.

Do I need special permission to use the questionnaire?
You may use the questionnaire within your practice as part of a full vision screening. Contact us if you have questions.