Please provide a brief summary of any eye or vision concerns *
Your answer
Any history in your family of an eye turning resulting from a disease or other condition?
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If yes, please explain:
Your answer
Was there any related trauma, disease or condition that preceded or accompanied the onset of the eye turn?
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If yes, please explain:
Your answer
List any severe illness, bad falls, high fevers etc
Your answer
Has a neurological evaluation ever been performed?
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If yes, by whom? What were the results?
Your answer
Has an occupational therapy evaluation been performed?
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If yes, by whom? What were the results?
Your answer
VISUAL HISTORY
At what age was it first noticed or suspected that an eye was turning?
Your answer
Did the eye begin turning suddenly or gradually?
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Does the eye turn in, out, up, down? Check all that apply
Is it always the same eyes that turn?
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If yes, which eye?
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Is the eye turn always present?
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If no, under what conditions is it present?
Your answer
Does the eye always turn in the same amount?
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If no, explain:
Your answer
Do you notice if the eye turns more when you look
Yes
No
Up close
In the distance
To your left
To your right
Up
Down
Yes
No
Up close
In the distance
To your left
To your right
Up
Down
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Does one pupil ever appear to be larger than the other?
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Do you ever notice one or both eyes shaking rapidly?
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Does your child report you experience any of the following?
Apart from the above, is there anything else hindering your vision?
Your answer
Do you feel your vision limits your daily activities in any way?
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If yes, please explain:
Your answer
PREVIOUS TREATMENTS
Has you ever had a previous visual evaluation?
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When was the evaluation? What was the results and recommendation?
Your answer
Were glasses, contact lenses or other optical devices recommended or prescribed?
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Are they worn?
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Does the eye turn less when the prescription is worn?
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Have you been told that you have amblyopia or a lazy eye?
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Has there been any treatment using an eye patch?
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If yes, please describe when patching was started, how the patching was done, including the age it started, the eye patched, the duration of treatment and an estimate of the results:
Your answer
Has there been any surgical treatment?
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If yes, describe the surgery, including the age surgery was performed, the number of operations, the eye(s) operated on, and an estimate of the cosmetic and subjective results:
Your answer
Was the surgeon satisfied with the results of the surgery?
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If no, explain:
Your answer
Were you satisfied with the results of the surgery?
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If no, please explain:
Your answer
Have surgical results been maintained?
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If no, please explain:
Your answer
Has there been any visual therapy?
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If yes, who was the doctor? Could you describe the visual therapy, including duration, the age at which it started and an estimate of results:
Your answer
Are you here for a second opinion regarding surgery or other treatment?
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Please list any other information that you feel would be helpful / important in our evaluation and/or treatment:
Your answer
It is often beneficial for us to discuss examination results and to exchange information with other professionals involved in your care. Do you agree to permit information from your 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 visual condition? *
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. *
Depending on the COVID situation in NSW, you 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.
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How did you hear about us?
Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email or sms?
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