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Children’s Vision
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Child Questionnaire
New Patient - Child Questionnaire
Welcome to Total Optical
Thank you for choosing our practice. Please provide the following information
Patient Details
Child's Name
(Required)
First
Last
Date of Birth
(Required)
Day
Month
Year
Sex
(Required)
Female
Male
Grade
(Required)
School
Medicare Card Number
(Required)
Medicare Reference Number (Number next to childs name)
(Required)
Medicare Expiry
(Required)
Your main concerns/reason for examination
(Required)
Parent/Guardian 1 Name
(Required)
Parent/Guardian 1 - First Name
Parent/Guardian 1 - Last Name
Parent/Guardian 1 Mobile
(Required)
Parent/Gaurdian 1 Home phone
Parent/Guardian 1 Email
(Required)
Parent/Guardian 2 Name
Parent/Guardian 2 - First Name
Parent/Guardian 2 - Last Name
Parent/Guardian 2 Mobile
Parent/Guardian 2 Home phone
Parent/Guardian 2 Email
Home Address - Parent/Guardian 1
(Required)
Street Address
Address Line 2
City
State / Province / Region
Post Code
Home Address - Parent/Guardian 2 (If different from Parent/Guardian 1)
Street Address
Address Line 2
City
State / Province / Region
Post Code
Postal Address (If different from Home Address)
Address Line 1
Address Line 2
City
State / Province / Region
Post Code
Does child live with both parents?
(Required)
Yes - Both parents
No - Parents separated
If no or other, please specify if there is a restriction to the release of confidential information, particularly if consent orders are in place.
GP's Name
GP's Practice/ Address
Developmental History
Birth Weight
Birth order eg. First child, second, twin etc
(Required)
Did child have normal delivery?
(Required)
Yes
No
Untitled
Premature
Caesarean
Humidicrib
Any Medications
Overdue
Forceps
Phototherapy for jaundice
Mother is/was Smoker
Did child come when expected?
(Required)
Yes
No
Was child well after birth?
(Required)
Yes
No
Did child gain weight normally?
(Required)
Yes
No
Did child bottom shuffle?
(Required)
Yes
No
Was mother well during pregnancy?
(Required)
Yes
No
When did child say first words?
(Required)
When did child first speak in sentences?
(Required)
When did child correctly name colours?
(Required)
What is child's preferred hand?
(Required)
Right
Left
Still developing
At what age did child definitely become right or left handed?
Do you consider child's co-ordination to be as expected for age?
(Required)
Yes
No
At what age could child tie shoe laces?
(Required)
At what age could child do up buttons?
(Required)
At what age could child use scissors?
(Required)
General Health
Has child has any serious illness or injury requiring hospitalisation?
(Required)
Yes
No
If yes, please give a brief description
Has child had any episode of high fever for more than 48hrs?
(Required)
Yes
No
If yes, please give brief description?
Has child had any history of recurrent ear problem?
(Required)
Yes
No
Have tubes been inserted?
Yes
No
Does child suffer from any other chronic or recurrent illness (eg. asthma, epilepsy)
(Required)
Yes
No
If yes, please give brief description?
Has child been diagnosed with Attention Deficit Disorder (ADD)?
(Required)
Yes
No
Has child had speech therapy?
(Required)
Yes
No
Has child seen an Occupational therapist?
(Required)
Yes
No
Does child take any medication?
(Required)
Yes
No
If yes, please give brief description
(Required)
Visual History
Does one eye turn in or out?
(Required)
No
Yes - In
Yes - Out
If yes, when was this first noticed?
(Required)
How often is turn noticed?
(Required)
When is turn noticed? (eg when eating, drawing)
(Required)
Has child has a previous visual examination?
(Required)
Yes
No
If yes, when was the last exam?
(Required)
Were glasses prescribed?
Yes
No
Has patching of one eye been prescribed?
(Required)
Yes
No
If yes, how long was patch worn?
Does child dislike bright light especially when outside?
(Required)
Yes
No
Does child screw up one eye when in bright light?
(Required)
Yes - Right eye
Yes - Left eye
No
Educational History
Has child's school progress been as expected for ability?
(Required)
Yes
No
Does child have difficulty with any of the following?
(Required)
Reading
Writing
Spelling
Maths
None
Has child repeated a grade?
(Required)
Yes
No
Has there been any remedial teaching?
(Required)
School based
Private tutor
None
Signs of Focusing and Eye Teaming Problems
Please select the boxes next to any problem that seems to occur often for your child
Signs of Focusing and Eye Teaming Problems
(Required)
Covers or Closes one eye when reading
Complains of eye strain
Complains of headaches
Complains of double vision
None
Untitled
(Required)
Complains of blurred vision when reading
Rubs eyes
Complains of words moving on page
Inattentive
None
Untitled
(Required)
Poor reading comprehension
Loses place when reading
Complains of blurred vision looking from desk to board
Holds books very close
None
Signs of Tracking Problems
(Required)
Loses place often
Skips words and lines often
None
Untitled
(Required)
Uses finger to keep place
Short attention span when reading
None
Signs of Visual Processing Disorders
(Required)
Trouble learning left and right
Reverses letters and numbers
Mistakes words with similar beginnings
Poor recall of visually presented material
Slow copying and completing worksheets
None
Untitled
(Required)
Can respond orally but not in writing
Trouble learning basic math concepts of size and magnitude
Untidy
Trouble copying from board to book
Doesn't recognise the same word on a repeated page
None
Untitled
(Required)
Trouble with spelling and sight word vocabulary
Seems to know material, but does poorly on tests
Erases excessively
Poor reading comprehension yet good comprehension when read to (listening)
None
How did you first hear about our practice?
Untitled
Friend or Relative
Health Care Practitioner
Previous Patient
Teacher
Other
Untitled
Google/Website
Facebook
Do you have Health Fund Extras (Optical Cover)?
(Required)
Yes
No
Health Fund Name
Comments
Your Privacy
At Total Optical your privacy is our priority. Your personal information that we collect and hold about you is handled with the utmost confidentiality and security and in accordance with the Privacy Act. For more information on how we manage your privacy, or for a copy of our privacy policy, please contact our practice. From time to time we may send you information on education relating to eye care and diseases, promotional offers and invitations to events and our practice newsletter. Do we have your permission to send this material to you?
(Required)
Yes
No
Consent
(Required)
I agree
I authorise that all the information I have provided you is correct. I consent to the release of confidential information from my child’s medical records in
the understanding that this will be done for the benefit of my child’s visual or medical welfare.
CAPTCHA
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Blog
Eyecare
AVULUX
Eyewear
Children’s Vision
Dry and Watery Eye Clinic
Meibomask
Contact Us
Book Online
Call Now
