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)
Parent/Guardian 1 Name(Required)
Parent/Guardian 2 Name
Home Address - Parent/Guardian 1(Required)
Home Address - Parent/Guardian 2 (If different from Parent/Guardian 1)
Postal Address (If different from Home Address)
MM slash DD slash YYYY
Sex

Developmental History

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General Health

Visual History

Educational History

Does child have difficulty with any of the following?(Required)
Has there been any remedial teaching?(Required)

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
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Signs of Tracking Problems
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Signs of Visual Processing Disorders
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How did you first hear about our practice?

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Your Privacy

Consent(Required)