Questionnaire

Private and Confidential

Please fill in the following information about your child prior to their appointment. The history and background information helps us determine what examination routines will best apply to your child.

Patient Name*

Home Phone

Mobile Number

Email*

Address (please include postcode)

Childs Date of Birth

Name of School

Grade

Teachers Name

Fathers Name

Occupation

Mothers Name

Occupation

Have you been to another Optometrist within the last 36 months?

If so, can you remember whom you saw?

Who recommended you to our practice?

Family Doctor's name

Suburb

What other professionals have you consulted?

Do you have a Private Health Fund?

please list

List any medication your child is on

A. Present Situation

1. What is the main reason for your visit?

2. In what way does your child seem to have visual difficulty?

3. Does your child complain about their vision?

4. Does your child report any of the following, and if so, please write in the box when? (e.g. Often)

Headaches	Blurred Distance Vision	Vision Blurred when Reading	Double Vision	Sore or Tired Eyes

B. Visual History

How long ago was the difficulty noticed?

List Previous Visual Examinations

Date	Doctor/Optometrists Name	Results

Eyes frequently bloodshot?

When?

Excessive Rubbing?

When?

Excessive blinking?

When?

Getting lost in a book?

When?

Tilting head when reading?

When?

Bumping into objects?

When?

Poor general co-ordination?

When?

Large pupils in normal light?

When?

Bothered by light?

When?

Holding reading close?

When?

Closing one eye? (in the sun or reading)

When?

Covering one eye?

When?

C. School

1. Childs age at time of entrance?

2a. Does your child like School?

2b. Does your child like his/her Teacher?

3. Has a grade been repeated?

Which grade?

4. Has there been any school difficulties?

please explain further

5. Is school work:

6a. Are there any subjects which seem particularly easy for the child?

6b. Are there any subjects which seem particularly difficult for the child?

7. Does the child reverse letters/numbers?

8a. Does your Child have difficulty with: Spelling?

8b. Does your Child have difficulty with: Reading?

8c. Does your Child have difficulty with: Comprehension?

8d. Does your Child have difficulty with: Mathematics?

8e. Does your Child have difficulty with: Writing?

D. Gross Motor Development

Crawled at age

Walked alone at age

Hand preference clearly indicated by age

Writing R/L hand

Sport R/L hand

How many hours a day watching Television?

How many hours a day on the devices? (including gaming)

Please select if your child answers 'yes' to any of the listed. (please hold the control key down to select multiples.)

E. Illness

Please select if your child answers 'yes' to any of the listed. (please hold down the control key to select multiples)

F. Habits

Please select if your child has any of the following. (please hold the control key down to select multiples.)

G. Family History

Seizures

Intellectually Disabled

Reading Problems

Glaucoma

Twin

Crossed-eye or wall-eyed

Strong Glasses

Epilepsy

Cerebral Palsy

Allergies

Learning difficulties

Colour Vision Defect

Amblyopia (lazy eye)

Diabetes

Please list members of the family who have had visual attention and why:

Name	Age	Visual Situation

A. Present Situation

B. Visual History

C. School

D. Gross Motor Development

E. Illness

F. Habits

G. Family History

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