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Pediatric Questionnaire



    Best Phone Number*

    Back-up Phone Number

    Children - answer these questions together with your Parent/Guardian: For every question, check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Answer every question.

    1. Do you have headaches or face pain?*

    2. Do your eyes hurt and / or does it hurt to move your eyes?*

    3. Do you have neck pain or a stiff neck or upper back pain?*

    4. Do you have stomach aches or nausea?*

    5. Do you get car sickness or motion sickness?*

    6. Did you get sick in the car seat when you were a small child?*

    7. Do you get sick to your stomach or nauseous on swings or circular rides?*

    8. Does riding in the car give you headaches or stomach aches?*

    9. Do you have trouble reading in the car?*

    10. Do you feel clumsy or klutzy or uncoordinated?*

    11. When you are walking, do you bump into people or furniture or door frames?*

    12. Do you feel funny or dizzy when you bend over and stand back up quickly?*

    13. Are you anxious or nervous?*

    14. In grocery stores or malls, do you stay close (cling) to your Mom or Dad? (Do you feel
    uncomfortable in grocery stores or malls?)*

    15. Do you tend to play alone or with just a few other kids? (Do you tend to play apart from the
    main group of kids?)*

    16. Is reading hard for you or are you a slow reader?*

    17. Do you have to read the same thing a couple of times to really understand it?*

    18. Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading?*

    19. Do you skip lines or lose your place when you are reading?*

    20. When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?*

    21. Do bright lights hurt your eyes?*

    22. Do you close or cover one eye to make it easier to see?*

    23. Do you have trouble catching baseballs or footballs or Frisbees?*

    24. Do you ever see two of everything (double vision)?*

    25. Is it hard for you to watch 3-D movies?*

    26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry?*

    27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?*

    Parent/Guardian: Has your child ever been diagnosed with:

    Learning disability (LD)?*

    Reading disability?*


    Lazy eye?*

    Migraines or headache disorder?*

    Traumatic brain injury or concussion?*

    ADD/ ADHD?*

    Are your child’s verbal skills far ahead of their reading skills?*

    Does your child blink their eyes a lot / much more than most children?*

    Has your child ever had an eye operation?*

    On an average day, how much are you bothered by the 8 symptoms listed below? (Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)






    Unsteady when walking*

    Sensitivity to light*

    Reading difficulty*

    Please record any additional symptoms you may be experiencing with learning difficulties in school or specific concerns that you have about your eyes / vision:

    How did you hear about us?:

    What Our Patients Are Saying

    Dr. Sonneberg and her staff are truly outstanding. She is a most experienced, capable and understanding optometrist. My eye exam for prism glasses was extremely thorough and her assistant Michelle picked out frames for me that were best suited for my needs. It was a great experience for me and it will be for you too. I highly recommend her.

    Susan S.

    This was such an amazing experience. They made me feel comfortable and made sure I knew everything that was going on. Dr. Sonneberg was absolutely amazing and her staff were so great as well. I would highly recommend going to them with any eye issues you may be experiencing or related symptoms. She definitely changed my life.

    McKenzie C.

    Exceptional experience from start to finish. All staff is extremely friendly and knowledgeable. Dr. Sonneberg is patient and kind. I am forever grateful for this team for helping me discover a diagnosis and treatment for my condition that has had me very sick for over 2 months. Highly recommend.

    Sarah C.

    I can’t even put into words how validated & happy I feel today after visiting Dr. Sonneberg’s office. From the front staff, to the doctor, to the location everything was perfect. She makes you feel so comfortable and truly wants to get to the root cause of your issues and find you answers, no matter what. She is very thorough and honest to get you to the best you can be. I am so excited to finally be diagnosed with converge insufficiency & vertical heterophoria and am on my path to recovery. If you are having any uncomfortable vision issues, neck or shoulder pain, a head tilt, dizziness or anxiety you need to see her immediately. It’ll change your life I promise you that!

    Sierra B.

    Dr. Sonneberg does a thorough examination. She is never satisfied until the refraction she prescribes is as good as it can be. She is patient and persistent in her efforts to help her patients.

    Denise J.

    My experience here was very positive. The staff is all very friendly and accommodating. Dr. Sonneberg's exam was thorough. This was my first visit and she took the time to learn in detail about my vision history and specific vision problem. She made an excellent recommendation as far as further treatment I may require. I felt no pressure to spend any more than I'd planned and no service or product was "pushed" on me as a prior writer complained. I have no problem recommending this office to anyone.

    UPDATE: It's been 5 years since I wrote this first visit review. Nothing I said then needs to be changed. I was there this morning and my visit could not have been pleasanter. I'd give 10 stars if I could.

    Beth B.

    My son and I are new patients of Dr. Sonnenberg. After my initial visit with Dr. Sonnenberg, I had an emergency; I called her. She told me to come right over! She is very caring, compassionate, considerate, and warm. She took care of me right away. She is an amazing doctor! I can't imagine going to anyone else. Her office staff is friendly, courteous and knows their stuff! The office is relaxing; no rushing around! I will be a patient of Dr. Sonnenberg's forever! If you are looking for a good optometrist, she is the one to see. I travel from Coral Springs to see her. Thank you Dr. Sonnenberg and staff!

    Penny D.

    Love this office!! Dr Sonneberg is so patient and friendly, and has really made a difference in my son's vision!! She is very thorough too! Her office staff is always smiling, having cute interactions with my kids, and very on the ball and organized. Best eye doctor we've ever been to!

    Chani R.

    Dr. Sonneberg and her team are incredible! This was hands down the best experience I’ve ever had buying glasses and having my eyes checked. Deena and Dr. Sonneberg have amazing expertise in selecting frames and helped me pick ones that I never would have chosen, but are beyond perfect. And my eye exam with Dr. Sonneberg was very efficient and easy, and she took time to answer all of my questions and make sure I was comfortable with my contact lenses and glasses. I can't recommend Dr. Sonneberg’s office highly enough— a perfect experience.

    Hadas A.

    I have been coming here for years and always have a great experience with Dr Sonneberg and the staff! They are very friendly and welcoming! Their attention to detail and the quality you get with your exam and fitting of glasses/contacts is the reason I keep coming back! Highly recommend!

    Brett S.