Children's Vision Questionnaire

Child's Full Name

First NameLast Name

Child's date of birth

Parent/ Guardian's Name

First NameLast Name

Contact phone number:

Address

Street Address

CityState

Postal code

Email Address

example@example.com.au

Medicare card number details:

Medicare card patient reference number:

Medicare card expiry:

Child's school year level:

School name:

Teacher's name:

Current general practitioner (GP) name and clinic:

What is the main reason for your child's visit?

Please select the options that apply to your child's birth:

Please provide further information:

Did your child crawl and hands and knees?

YesNo, my child skipped the crawling stage

If yes, at what age?

When did your child say their first words?

When did your child first speak in sentences?

Do you consider your child's general coordination to be as expected for their age? (Includes catching skills)

YesNo

What is your child's preferred hand?

Right-handedLeft-handedAmbidextrous (no preference yet)

Does/Did your child suffer from any of the following:

Please provide further information:

Does your child take any medications?

YesNo

Please list any medications:

Does your child suffer from any allergies in general and/or to any medications or eye drops?

YesNoNot Sure

Please list any allergies:

Is there a family history of (please select all options that apply):

Please provide further relevant information below:

Has your child ever had a previous eye examination?

YesNo

If yes, when was your child's last eye examination?

Does your child wear spectacles?

YesNo

If yes, please select the corresponding reasons for the spectacles below:

Please provide further relevant information below:

Has your child received any diagnoses for any of the following conditions (please select all options that apply to your child):

Please provide further relevant information below:

Has your child seen or is currently seeing any of the following health care practitioners? Please select all options that apply to your child.

Please provide further information including: the age at which you child has seen the health care professional, as well as how long your child has seen or is currently seeing them for.

Is your child over 4 years-old?

YesNo

Does your child experience challenges with any of the following learning skills:

ReadingWritingSpellingMathematics

Has your child reported any of the following? Please select the option that corresponds best to your child.

Rows	Never	Sometimes	Often	Always	N/A
Headaches
Blurry vision
Double vision
Eye strain/Tired eyes
Tired by the end of the day
Eye rubbing
Covers or closes one eye when reading
Poor concentration
Losing track when reading
Words look blurry when reading
Words moving on the page
Poor reading comprehension
Blurred vision when looking from desk to board
Holds things very close

Please select the option that corresponds best to your child.

Rows	Never	Sometimes	Often	Always	N/A
Challenges learning left from right
Reversing numbers and/or letters
Skips lines and words often
Uses finger to keep place on page
Untidy handwriting
Mistakes words with similar beginnings
Poor recall of visually presented material
Slow copying and completing worksheets
Can respond orally but not in writing
Challenges with learning basic maths concepts
Challenges with copying from the board to book
Poor concentration/attention when reading & writing
Challenge to recognise the same words repeated on a page
Challenges with spelling and sight word vocabulary
Seems to know material but challenged on written tests
Erases excessively
Below average reading comprehension

When your child reads, do the words look clear all the time?

YesNoUnsure

When your child reads, do the words remain still on the page all the time?

YesNoUnsure

Has your child reported anything else of concern that you would like to bring to our attention?

Should there be any further documents or referrals you would like the Optometrist to view, please forward all information to our email address: info@bassendeanoptical.com.au

How did you hear about us?

Other: