• Primary School Age 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 48 hours' notice if you are unable to keep this appointment.

  • GENERAL INFORMATION:

  • Gender*
  • Birth Date *
     - -
    2 digit day, 2 digit month, 4 digit year

  • (For Medicare claiming purposes)

  • Parents DOB*
     - -
    2 digit day, 2 digit month, 4 digit year

  • RESPONSIBLE PERSON INFORMATION:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you find us?
  • Format: (000) 000-0000.
  • Is your child especially afraid of doctors?

  • MEDICAL HISTORY

  • Format: (000) 000-0000.

  • PAEDIATRICIAN

  • If applicable

  • Format: (000) 000-0000.
  • Medications currently using, including vitamins and supplements
    Rows
  • List illnesses, bad falls/concussions, high fevers, etc.
    Rows
  • Is your child generally healthy?
  • Are there any chronic problems like ear infections, asthma, hay fever, allergies?
  • Other treatments/evaluations etc.
    Rows

  • NUTRITIONAL INFORMATION

  • Current diet?
  • Fish
  • Medical History: Please mark yes/no on conditions that apply
    Rows
  • Family History: Please mark “Yes” / "No" on all conditions that apply and list the family member including cousins, aunts, uncles who has the following condition?
    Rows

  • DEVELOPMENTAL HISTORY

  • Was the pregnancy full term?
  • Did the mother experience any health problem during the pregnancy?
  • Did the mother drink, smoke or take drugs during the pregnancy?
  • Was it a natural Birth?
  • Were there any complications before, during or immediately following delivery?
  • Were forceps used?
  • Was there ever any reason for concern over your child's general growth or development?
  • Developmental Milestones: Please list the age your child was able to complete the following tasks
    Rows
  • Rows
  • Child's dominant hand : right or left?
  • Has guidance been given in use of hand?

  • OCULAR HISTORY

  • Has your child's vision previously been evaluated?
  • Date of last evaluation
     - -
    2 digit day, 2 digit month, 4 digit year
  • Does your child report any of the following? (To be answered by the child not the parent)
    Rows
  • Have you, your child or anyone else ever noticed the following?
    Rows

  • TELEVISION VIEWING/LEISURE TIME ACTIVITIES

  • Does your child spend time using computer/tablet/video games?
  •  If yes,how much time?
  • How much time does your child spend outdoors on a daily basis?

  • SCHOOL

  • Does your child like school?
  • Does your child like his/her teacher?
  • Has a grade been repeated?
  • Is your child under tension or pressure when doing school work?
  • Has your child had any special tutoring,therapy, and/or remedial assistance?
  • Does your child like to read?
  • Does your child read voluntarily?
  • Does your child have difficulty spelling?
  • Overall school work is?
  • Does your child need to spend a lot of time/effort to maintain this level of performance?
  • How much time on average does your child spend each day on homework assignments?
  • Do you feel your child is achieving up to potential?
  • Does the teacher feel your child is achieving upto potential?

  • GENERAL BEHAVIOR

  • Are there any behaviour problems at school?
  • Are there any behaviour problems at home?
  • Does your child say and/or do things impulsively
  • Is your child in constant motion?
  • Can your child sit still for long periods?

  • FAMILY AND HOME

  • Please indicate which adult(s) he/she lives with?
  • Does your child spend time with any other person, not in the home?
  • Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)?
  • Does your child seem to have adjusted to this situation?
  • Was counselling /therapy undertaken?
  • If yes, is it on-going?
  • Is family life stable at this time?
  • How does your child get along with
    Rows

  • 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.

  • Date
     - -
    2 digit day, 2 digit month, 4 digit 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.

  • Date
     - -
    2 digit day, 2 digit month, 4 digit 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.

  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: