Kiddies Eye Care Geelong Child Pre-Exam Form

Kiddies Eye Care Geelong- Child Pre-Examination Form

Please complete this form prior to your appointment and bring any current spectacles
Patient Name

First NameLast Name
DOB

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemaleNon BinaryPrefer not to say
Personal Pronoun
Is the patient of Aboriginal or Torres Strait Islander Origin?
Education Level
Sports/Hobbies
Is the patient interested in:

SpectaclesContact lensesSunglassesMyopia Control
Brief Summary of any eye or vision concerns
Reason for Visit

Routine eye checkLazy/turned eyeReferralFailed Maternal Health Nurse CheckSchool Nurse ReferralBehavioural Concerns
Other reason
Visual History
Date and place of last eye exam
Any history of the following conditions for the patient?

No history of eye conditionsLazy/turned eyeHigh spectacle prescriptionDry eyesGlaucomaMacula DegenerationEye SurgeryEye InjuryOther
Any family history of the following conditions?

No known family historyLazy/turned eyeHigh spectacle prescriptionDry eyesGlaucomaMacula DegenerationEye SurgeryEye InjuryOther
Medical History
GP Name
GP Clinic
Does the patient currently or have they ever experienced any of the following?

No known health issuesHigh blood pressure/heart issuesEpilepsyHead Injury (Concussion)DiabetesThyroid issuesHeadaches/migrainesChromosomal Addition/Deletion/TranslocationAllergies (please specify in notes)Other
Notes
Current medications
Developmental History

Please complete the following if the patient is under 16 years of age
Pregnancy Term (weeks/days)
Pregnancy and birth free from complications
Has the child met developmental milestones? eg crawling, walking, talking
Has the child had a hearing test?
Are they currently seeing a specialist?
Is the child seeing any allied health professionals? eg speech therapist, occupational therapists etc.
Do you consent for us to send a summary of your child's examination to your specialist/ allied health professional upon request or after referral?
About your Child:
Does your child have difficulty with

ReadingFatigue when readingConcentrationSpellingHold devices/books closeSkipping words/lines/loses placeDifficulty recalling what is readWritingRubbing eyes/blinking eyesMathsHeadachesTummy AchesAnxietyNot having difficulty in these areasOther
Other
Is your child experiencing behavioural Issues?
Has your child been diagnosed with a spectrum/developmental disability?
Are happy for us to mindfully discuss your child's issues in front of them?

YesNo
How did you find us?

Word of mouthGoogleReferral
Is there anything else you would like us to know?
Please note that by completing this form you consent to participating in an eye examination. Your eye examination may include, but may not be limited to the following tests: Visual acuity, to determine the need for glasses or a change in prescription for glasses or contacts, a binocular vision assessment and ocular health, these results will be documented in our medical records. At Kiddies Eye Care our priority is your eye health. Please notify the Optometrist if you do not wish to participate in a specified test.

Additionally we are a private billing practice and payment is required at time of consultation. Eligible Medicare card holders will receive a rebate into their account.

Please call us on (03) 5202 5911 for further clarification of fees.
Parent/Guardian/Carer Name 1

First NameLast Name
Relationship to patient
Parent/Guardian/Carer Name 2

First NameLast Name
Relationship to patient
Do you consent to anyone acting on your behalf

GrandmaGrandpaAuntyUncleOther
Please provide names of the people who can act on your behalf
Signature

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Date

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Date
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Kiddies Eye Care Geelong- Child Pre-Examination Form

Visual History

Medical History

Developmental History

About your Child: