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Vision Follow Up

1. Please enter your child's information below:

First Name
Last Name
Parent/ Guardian Phone Number
Parent/ Guardian Email

2. What school does your child attend?

3. What grade is your child in?

4. Has your child been seen by an eye care professional?

Eye Care Professional Information:

What is the name of the eye care professional:
What is the date your was seen by an eye care professional: (MM/DD/YYYY)

Were corrective lenses (glasses or contact lenses) prescribed for your child?

My child is to wear his/her glasses/contacts:

Please enter an 'other' value for this selection. * This question is required.

Please select any ocular defect(s) noted by the eye care professional. (Select all that apply.)

Myopia
Astigmatism
Hyperopia
Muscle Imbalance
None
Other (Please List) Please enter an 'other' value for this selection.

Were any of the following needed for your child? (Select all that apply.)

Vision Therapy
Surgical Treatment
Medical Treatment
None
Other (Please List) Please enter an 'other' value for this selection.

5. Is there any additional information regarding your child's vision that you would like the Allegan County Health Department's hearing and vision technicians to know?