optimeyes - Infant Toddler Questionnaire

INFANT/TODDLER VISION QUESTIONNAIRE
Thank you for carefully completing this questionnaire. The information you supplied will allow us to provide a more comprehensive evaluation and better meet your child's specific visual needs.

If you have any questions, please contact our office at 02 9982 1039 prior to your appointment.

We request a minimum of 24 hours' notice if you are unable to keep this appointment.

PLEASE RETURN THIS FORM TO info@optimeyes.com.au 48 HOURS PRIOR TO THE APPPOINTMENT
GENERAL INFORMATION:
Child's Full Name *

First Name Middle Name Last Name
Gender *

Male Female
Birth Date *

Day Month Year
Medicare # *
10 digit number
Ref # *
the number next to your name
Exp Date *
(For Medicare claiming purposes)
Parents name *
Parent’s Ref # *
Parents DOB *

Day Month Year
Private Health Fund Name
Private Health fund membership number
Ref #
the number next to your name
RESPONSIBLE PERSON INFORMATION:
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Mother’s Name
Mobile
Email
Father’s Name
Mobile
Email
Name of school
Grade
Teacher
Reason for Visit
Were you referred to our office

Yes No
Whom may we thank for this referral?
Phone
Is your child especially afraid of doctors?

Yes No
MEDICAL HISTORY
GP's Name
Phone Number
GP's Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
If applicable
Pediatrician’s Name
Phone Number
Pediatrician’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Medications currently using, including vitamins and supplements

	Medications	Condition
1
2
3
4
5
6

List illnesses, bad falls/concussions, high fevers, etc.

	Illness	Age	Severity (Mild- Severe)	Complications
1
2
3
4

Is your child generally healthy?

Yes No
If no, explain
Are there any chronic problems like ear infections, asthma, hay fever, allergies?

Yes No
If yes, please list

Other treatments/evaluations etc. Additional space available at the end of the questionnaire

	Yes / No	By whom	Results/Recommendations
Neurological
Psychological
Occupational therapy
Speech Therapy
Other

NUTRITIONAL INFORMATION
Current diet?

Good Fair Poor
Does your child eat a good variety of fruit and vegetables?

Yes No
Fish

Yes No
Does your child: Like sweets or crave sweets

Yes No

Medical History: Please mark yes/no on conditions that apply

	Yes/No
Crossed Eye
Amblyopia (lazy eye)
Learning Disability
ADD/ADHD
Asperger's Syndrome/Autism
Juvenile Diabetes
Ehlers Danlos
Chromosomal Imbalance
Brain Tumor / Brain Injury
Epilepsy/Seizure

DEVELOPMENTAL HISTORY
Was the pregnancy full term?

Yes No
Did the mother experience any health problem during the pregnancy?

Yes No
If yes, explain
Did the mother drink, smoke or take drugs during the pregnancy?

Yes No
Was it a natural Birth?

Yes No
Were there any complications before, during or immediately following delivery?

Yes No
If Yes, please explain
Birth weight?
Apgar score at birth?
After 10 minutes?
Were forceps used?

Yes No
Was there ever any reason for concern over your child's general growth or development?

Yes No
If yes, explain
Has your child received any special developmental assistance?

Yes No
If yes, explain
How many hours daily does your child sleep?

Hour Minutes
During waking hours is/was your child
In a playpen?

Yes No
For how long?

Hour Minutes
In a walker?

Yes No
For how long?

Hour Minutes
In a seat?

Yes No
For how long?

Hour Minutes
What things can your child do very well?
What things, if any, are difficult for your child?

	Age
Responsive smile
Crawl (stomach on floor)
Roll over
Creep (stomach of floor)
Sit up alone
Respond to words and names
Say single words
Give first name
Stack blocks
Walk alone
Scribble spontaneously
Kick a ball
Walk up steps with help
Use two-word sentences
Become toiled-trained
Put on some clothing alone

CONSENTS

RELEASE OF INFORMATION

IT IS OFTEN BENEFICIAL TO EXCHANGE INFORMATION AND DISCUSS YOUR CHILD'S RESULTS WITH HIS/HER SCHOOL AND OTHER PROFESSIONALS INVOLVED IN HIS/HER CARE. PLEASE SIGN BELOW TO AUTHORISE THIS EXCHANGE OF INFORMATION.

I give my consent to make copies of my child's record and share any pertinent data from this exam to the school and other professionals. I also give my consent to provide any information to the health care providers

This authorisation shall be considered valid throughout the duration of treatment.
Signature

Clear
Date

Day Month Year
CONSENT TO PHOTOGRAPH

PLEASE SIGN BELOW TO AUTHORISE.

From time to time it may be necessary and useful to photograph your child in order to obtain records of eye movements, body movements and the like. The records are for the express use of the optometrist and therapist to gauge and monitor change and progress. They will not be provided to any external sources without your prior consent.

I give my consent for my child to be photographed if clinically necessary.
Signature

Clear
Date

Day Month Year
CONSENT TO MAKE BODY CONTACT

PLEASE SIGN BELOW TO AUTHORISE.

At times it may be necessary at times to guide you child with prompts which may require either the optometrist or therapist to gently touch your child. This will mostly be on the head, arm or leg and occasionally trunk or hips. This will usually be during therapy or during the assessments. We will always check with you first and you will always be present at these times.

I give my consent for the optometrist or therapist to make body contact with my child if clinically necessary.
Signature

Clear
Date

Day Month Year
Should be Empty:

	Yes / No	If yes, when?
An eye turns in or out
Reddened or encrusted eyelids
Frequent sties
Eyes in constant motion
Eyelids droop
Stares at bright lights or repeatedly flicks objects in front of face
Is abnormally bothered by bright light
Seems visually unaware
Has watery eyes
Turns head to use one eye only
Tilts head to one side
Moves objects very close to look at them
Squints while looking at objects
Blinks excessively
Tends to rub eyes
Covers or closes one eye
Stumbles over objects or is clumsy
Poor motor control
Lacks interest in looking at objects or seeing
Unable to see distant objects
Unable to transfer object from hand to hand, or crossing the mid line of the body
Is unable to stack blocks or other objects

INFANT/TODDLER VISION QUESTIONNAIRE

GENERAL INFORMATION:

RESPONSIBLE PERSON INFORMATION:

MEDICAL HISTORY

NUTRITIONAL INFORMATION

DEVELOPMENTAL HISTORY

NUTRITIONAL INFORMATION

VISUAL HISTORY

PRE-SCHOOL/DAYCARE

CURRENT ABILITIES/BEHAVIOR

CONSENTS

RELEASE OF INFORMATION

CONSENT TO PHOTOGRAPH

PLEASE SIGN BELOW TO AUTHORISE.

CONSENT TO MAKE BODY CONTACT

PLEASE SIGN BELOW TO AUTHORISE.

	Name / Relationship	Age	Visual Situation
1
2
3
4