Questionnaire prior to children’s eye examination
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1.
Child’s name:
(Required.)
*
2.
Child’s age:
(Required.)
*
3.
Child’s personal code:
(Required.)
*
4.
Does your child wear eyeglasses?
(Required.)
Yes, minus glasses
Yes, plus glasses
No
5.
What is the prescription strength of the child's glasses?
*
6.
Does either of the parents use eyeglasses?
(Required.)
Yes, minus glasses
Yes, plus glasses
Has used glasses but has undergone laser surgery or a procedure
No
*
7.
The reason for coming to the eye examination:
(Required.)
Vision Check
Vision deterioration
Other (please specify)
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8.
Your child was born:
(Required.)
Duly
Prematurely (please specify the week)
*
9.
Does your child have chronic diseases that we should be aware of? If so, please specify:
(Required.)
No
Yes
*
10.
Does your child use medicines? If so, please specify:
(Required.)
No
Yes
*
11.
Have you noticed a deterioration in your child's eyesight? If so, please specify:
(Required.)
No
Yes
*
12.
Have you ever noticed your child's eyes being crossed (Strabismus)? If so, please specify when:
(Required.)
No
Yes
*
13.
Has anyone in your family had amblyopia (lazy eye)? If so, please specify:
(Required.)
No
Yes
*
14.
Has anyone in your family had an eye disease? If so, please specify:
(Required.)
No
Yes
*
15.
Do you have any additional comments or concerns related to the eye examination?
(Required.)
*
16.
Why did you choose KSA Vision Clinic?
(Required.)
17.
How did you hear about KSA Vision Clinic?
I did my own research and searched online
I received a recommendation from a friend, acquaintance, or family member
I saw a post or advertisement on social media (Facebook, Instagram)
I saw information through another channel (e.g., a banner on Delfi, an article in Postimees, a video on TikTok, an advertisement in a gym, etc. Please specify):
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18.
Do you consent to the processing of your personal data?
(Required.)
I agree to the terms of personal data protection.
