PVS Well Child Vision Screening Tool Preschool Vision Screenings - Well Visits Gender * Female Male Month of Visit * January February March April May June July August September October November December Well Child Visit 3-Year 4-Year 5-Year 1. Was this WCV the child's initial vision screening? Yes No (rescreening was attempted at this visit) 2. Was there documentation of reviewing and updating the patient and family vision history? Yes : If yes, please note any positive findings: Yes - No Findings No Previous Diagnosis Known Neurodevelopmental Disorder Systemic diseases requiring eye surveillance Medication side effect profile Prematurity <32 weeks gestation Observation or History Recognized eye abnormality First degree relative with strabismus First degree relative with amblyopia Submit If you are human, leave this field blank.