Welcome to the Practice (Child with Complex Needs)
Thank you for making an appointment with Eyes2Learn Optometrists.  As a new patient with an complex needs, we need you to fill this form and the children or adult form on our menu bar.  These are important questions about you.  Please complete this form prior to your appointment to maximise your examination time.  If at any time you have any questions or concerns regarding your examination, please do not hesitate to contact us at hello@eyes2learn.com.  Thank you for your cooperation.
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Email *
Child's Full Name *
Parent/Guardian's Full Name
Have you filled in a Children or Adult Form? *
What is the main reason for your visit today?
MEDICAL HISTORY
Is your child generally healthy?
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If no, please explain:
Does your child have any other health conditions that we should be aware of?
Are there any chronic problems like ear infections, asthma, hay fever?
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If yes, please list
NUTRITIONAL INFORMATION
Does your child
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Is your child active?
Yes
No
Moderately
Extremely
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Are there periods of
Yes
No
Very high energy
Very low energy
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If you answered yes, please explain
DEVELOPMENTAL HISTORY
Full term pregnancy
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Did the mother have any health problems during pregnancy? If yes, please specify
Did the mother experience any birth complications? If yes, please specify
Were forceps used?
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Was there ever any reason for concern over your child's general growth or development?
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If yes, please specify
Did your child crawl (stomach on floor)?
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Did your child creep (on all fours?)
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At what age did your child walk?
At what age did your child developed a preferred side?
Was the child active?
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At what age did your child say their first words?
Was early speech clear to others?
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Is speech clear now?
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ACADEMIC HISTORY
Name of School and Year Level
Does your child like school?
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School work is
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Which subjects are above average?
Which subjects are average?
Which subjects are below average?
Does your child need to spend a lot of time / effort to maintain this level of performance?
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How much time on average does your child spend each day on homework assignments?
To what extent, do you assist your child with homework?
Do you feel your child is achieving up to potential?
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Does the teacher feel your child is achieving up to potential?
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Does your child seem to be under tension or extreme pressure?
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Has your child repeated a grade?
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If yes, which grade and why?
Has your child changed schools often?
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If yes, when?
Has your child had any special tutoring, therapy, and/or remedial assistance?
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If yes, when? where? From whom? For how long? What were the results?
Does your child like to read for pleasure?
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What is your child's attitude towards reading, school, his/her teacher, other youngsters?
Please list age at time of entrance to Pre-school / Kindergarten / First Grade
GENERAL BEHAVIOUR
Are there any behaviour problems at school?
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If yes, what?
Are there any behavior problems at home?
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If yes, what?
From your observation, what causes these problems?
Child's reaction to fatigue?
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Child's reaction to tension?
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Does your child say and/or do things impulsively?
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Is your child in constant motion?
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Can your child sit still for long periods?
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VISUAL HISTORY
Has your child been previously evaluated?
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When was the evaluation? What was the reason for the evaluation? What were the results and recommendation?
Were glasses, contact lenses or other optical devices recommended?
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Are they used?
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If not, why?
Why do you feel your child need a visual evaluation?
How long has this problem / difficulty been observed?
Is there any evidence from the school, psychological or other tests that indicates some visual dysfunction may be present?
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If yes, what?
LEISURE TIME ACTIVITIES
How much often and how much time is spent watching TV?
How much often and how much time is spent using the computer / video game?
What other activities occupy your child's leisure time?
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?
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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.
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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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