Welcome to the Practice (Child)

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Thank you for making an appointment with Eyes2Learn Optometrists. As a new patient, we need to ask some important questions about you and your child. Completing this form prior to your appointment will maximise your child's examination time. Thank you for your cooperation.

Email *

Child's Full Name *

Parent/Guardian's Full Name *

Address *

Postcode *

Child's Date of Birth *

YYYY

Parent/Guardian's Mobile *

Does the child live with both parents at the same address?

Yes

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Child's Medicare Number, Reference Number & Expiry *

Is your child covered by Private Health Insurance? *

Yes

If you answered yes, who is the Provider Health Fund Provider?

GP's Name & Medical Practice *

Year Level and Name of School

Were you referred to our our office? *

Yes

If yes, whom may we thank for this referral?

What is the main reason for your visit today? *

Has your child previously being assessed by the following? If so, please bring their report

Educational Psychologist

Optometrist

Speech Pathologist

Occupational Therapist

Ophthalmologist

Paediatrician

Has your child being diagnosed with any behavioural or learning difficulties?

Yes

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MEDICAL HISTORY

Does your child have health conditions that we should be aware of?

Please list any medication your child is currently taking

Please list any allergies your child has (food & medication)

Describe your child's current diet (Good, Fair, Poor)

Has your child ever being admitted to hospital? Was general anaesthesia required?

ACADEMIC HISTORY

School work is

Above average

Average

Below average

Other:

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Is your child having difficulty with any of the following?

Reading

Spelling

Writing

Maths

Behaviour

Has your child repeated a grade?

Yes

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DEVELOPMENTAL HISTORY

Did you experience any birth complications? If yes, please specify

Did your child have any developmental delays such as crawling, walking or talking, tying shoe laces? If yes, please specify

At what age did your child developed a preferred side?

VISUAL HISTORY

Does your child currently wear glasses?

Yes

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Eye Teaming Ability: Have you or your child reported the following?

Double vision

Headaches

Words moving on the page

Cover or close one eye when reading

Poor reading posture

Tilts head when reading / writing

Frequent blinking

Motion sickness / car sickness

Other:

Focusing Ability: Have you or your child noted the following?

Avoid small print

Become fatigued when reading

Complain of blurred vision when reading

Complain of eyestrain

Complain of frontal headache

Have a short attention span when reading

Hold a book very close

Rub his / her eyes when concentrating

Other:

Eye Tracking Ability: Have you or your child noted the following?

Lose place on the page often

Skip words and lines often

Use finger to keep his / her place

Poor eye hand coordination

Moves head when reading

Reads slowly

Reading comprehension decreases over time

Difficulty copying from the board

Other:

Visual Processing Ability: Have your or your child noted the following?

Respond orally but not in writing

Good verbal comprehension but poor reading comprehension

Seems to know material but does poorly on written material

Trouble learning left and right

Reverse letters and numbers

Untidy handwriting

Frequent erasing of written work

Poor organisation on a page

Writes neatly but slowly

Have trouble learning basic math

Not recognising the same words repeated on the page

Have trouble with spelling and sight word vocabulary

Mistake words with similar beginnings

Poor recall of visual material

Difficulty following a set of instructions

Have trouble learning letter/sound correspondence

Poor word attack skills

Other:

Motor ability: Have you or your child noted the following?

Poor gross motor coordination

Difficulty with scissors / small hand tools

Dislike / avoids sports

Difficulty catching / hitting ball

Other:

It is often beneficial for us to discuss examination results and to exchange information with your child's paediatrican, day care, preschool, and/or other professionals involved in his/her care. Do you agree to permit information from your child's examination to be forwarded to other health care providers upon their written requests or upon the recommendation of EYES2LEARN OPTOMETRISTS when it is necessary for the treatment of your child's visual condition? *

Yes

Depending on the COVID situation in NSW, you and your child maybe required to wear a mask during the consultation. If you have your own mask, please bring this with you to the consultation. Please also observe the latest COVID guidelines.

Yes. I understand

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We request a minimum of 24 hours notice if you are unable to keep this appointment. Please be on time for your evaluation so that we may have the maximum opportunity to evaluate your child's visual status. *

Yes. I understand

How did you hear about us?

Relative/Friend/Previous Patient

Internet Search/ Our Website

Social Media

Print Advert

Other

Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email or sms?

Yes

Maybe

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