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Welcome to the Practice (Infant & Toddler)
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.
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Email
*
Your email
Child's Full Name
*
Your answer
Parent/Guardian's Full Name
*
Your answer
Address
*
Your answer
Postcode
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Your answer
Child Date of Birth
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MM
/
DD
/
YYYY
Parent/Guardian's Mobile
*
Your answer
Does the child live with both parents at the same address?
Yes
No
Clear selection
Child's Medicare Number, Reference Number & Expiry
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Your answer
Is your child covered by Private Health Insurance?
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Yes
No
If you answered yes, who is the Provider Health Fund Provider?
Your answer
GP's Name & Medical Practice
*
Your answer
What is the main reason for your visit today?
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Your answer
Does your child have special needs, an eyeturn or brain injury? If so, there's an additional form you need to complete on our website.
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Yes. I need to fill in a Special Needs Form (Child)
Yes. I need to fill in an Eyeturn Form
Yes. I need to fill in a Brain Injury Form
No
MEDICAL HISTORY
Does your child have any health conditions we should be aware of?
Yes
No
Clear selection
If you tick yes, please specify
Your answer
Does your child have any chronic health problems?
Ear infections
Asthma
Allergies
Hayfever
Other:
Does your child have any allergies (including food and medication)
If you tick the above box, please specify
Your answer
Please list any medication (including vitamin and supplements) your child is currently taking
Your answer
Has your child had the following:
Yes
No
High Fever
Bad fall
A neurological evaluation
A pscyhological evaluation
An occupational evaluation
Being admitted to hospital
Yes
No
High Fever
Bad fall
A neurological evaluation
A pscyhological evaluation
An occupational evaluation
Being admitted to hospital
If you answered yes, please specify
Your answer
Is there any family history of the following?
Yes
No
Turned eye (Strabismus)
Lazy eye (Amblyopia)
Glaucoma
Learning disability
Chromosomal imbalance
Epilepsy or seizures
Other
Yes
No
Turned eye (Strabismus)
Lazy eye (Amblyopia)
Glaucoma
Learning disability
Chromosomal imbalance
Epilepsy or seizures
Other
If you answered yes, please specify
Your answer
DEVELOPMENTAL HISTORY
Full term pregnancy
Yes
No
Clear selection
Did the mother experience any health problems during pregnancy? If yes, please specify
Your answer
Was there any birth complications? If yes, please specify
Your answer
Was there any reason for concern over your child's general growth or development i.e. crawling, walking, rolling over, stacking blocks, responding to names, using 2-3 word sentences, putting on clothes)? If yes, please specify
Your answer
How many hours does your child sleep daily?
Your answer
What percent of the waking hours is/was your child in a playpen / walker / seat?
Your answer
What things can your child do very well?
Your answer
What things, if any, are difficult for your child?
Your answer
NUTRITIONAL INFORMATION
Describe your child's activity level
High
Moderate
Low
Clear selection
Does your child have any of the following?
Yes
No
Food allergies / sensitivities
Periods of very high energy
Periods of very low energy
Crave sweets
Yes
No
Food allergies / sensitivities
Periods of very high energy
Periods of very low energy
Crave sweets
Clear selection
If you ticked yes to any of the above, please specify
Your answer
What is your child's favourite food?
Your answer
What food does your child dislike or avoid?
Your answer
VISUAL HISTORY
Why do you feel your child needs a visual examination?
Your answer
Has your child's vision been previously evaluated?
Yes
No
Clear selection
If yes, when was the evaluation? What was the result and recommendation?
Your answer
Were glasses, contact lenses, other optical devices recommended?
Yes
No
Clear selection
If yes, what? Are they currently used?
Your answer
Was surgery, therapy or other treatment recommended?
Yes
No
Clear selection
If yes, what?
Your answer
Please check the observations and / or complaints that relate to your child
Reddened or encrusted eye lids
Frequent styes
Eyes in constant motion
Eyelid droop
Has watery eyes
Has a tendency to rub eyes
Is abnormally bothered by bright light
Stares at bright lights or repeatedly flicks objects in front of face
Blinks excessively
Lacks interest in looking at objects or seeing
Seems visually unaware
Unable to see distant objects
An eye turns in or out
Squints while looking at objects
Moves objects very close to look at them
Turns head to use one eye only
Tilts head to one side
Covers or closes one eye
Poor motor control
Stumbles over objects (or is clumsy) more than his peers
Unable to transfer object from hand to hand OR cross midline of the body
Unable to stack blocks or other objects
Other:
Does your child verbalise any problems / complaints about his/her eyes? or vision?
Yes
No
Clear selection
If yes, explain
Your answer
PRESCHOOL
If your child attends preschool, please fill out the following
Name of Preschool and Teacher
Your answer
Age at time of entrance to preschool
Your answer
Does your child like preschool?
Yes
No
Clear selection
Compared to other children his/her age, do his/her general performance and social skills seem to be?
above
equal to
or below
Clear selection
What preschool activities are easy for your child?
Your answer
What preschool activities are difficult for your child?
Your answer
Specifically describe any preschool / day care concerns / difficulties
Your answer
CURRENT ABILITIES / BEHAVIOUR
Can your child identify
Yes
No
Sort of
Colours
Letters and numbers
Yes
No
Sort of
Colours
Letters and numbers
Clear selection
Does your child draw / colour?
Yes
No
Clear selection
Is your child learning to read?
Yes
No
Clear selection
How is your child performing as compared to others his/her age?
Above average
Below average
Clear selection
How well developed is your child's spoken vocabulary?
Not very developed
1
2
3
4
5
Well versed
Clear selection
How well does your child understand / respond to spoken language?
Not responsive
1
2
3
4
5
Understands and responds well
Clear selection
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
No
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 visual status.
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Yes. I understand
Other:
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
No
Maybe
Clear selection
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