We ask you to take a few moments to complete this form. The purpose of collecting this information is to assist us in providing your child with the highest quality eye-care. All information will be treated in the strictest confidence in accordance with the Privacy Act. As you complete this history questionnaire we hope that you will recognize the thoroughness with which your child’s vision will be considered. The examination will take up enough time to permit a very complete investigation. It is desirable to have both parents present during the examination when possible.