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Binocular Disorder Questionnaire

About this Form

Form number: 272-7A

Audience:  MCPS Staff, School Staff, Teachers

Last revised: March 2018

INSTRUCTIONS: Following receipt of a private medical report with a diagnosis of a binocular disorder such as Convergence Insufficiency, please complete the following questionaire. Send to the DHOH/Vision Program, English Manor site, fax to 240-740-1804, or via e-mail to:

Adobe PDF Binocular Disorder Questionnaire78 KEnglish

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