Children’s Vision Questionnaire – On Line Form Please fill out this questionnaire carefully and submit it before your next appointment. The information supplied will allow for a more efficient use of time and will enable us to perform a more comprehensive evaluation of your child and to better meet your child's specific visual needs. If you have any questions or concerns prior to your appointment, please do not hesitate to contact us.Please enable JavaScript in your browser to complete this form.Patient's Name *FirstLastDate of Birth *Parent's Name *FirstLastPhoto of Patient Click or drag a file to this area to upload. Mobile Number *Home Phone NumberResidential Address *Postal Address *Email *Name of School *Grade *Teacher *GP Name and Medical Centre *Name of Private Health Fund *Does this include Extras Cover? *YesNoMedicare Number *Patient Reference Number *Expiry *Are your bank details registered with Medicare? *YesNoDo you have a Health Care Card? *YesNoHow did you hear about our practice?Do you consent to us sending you appointment reminders via SMS and/or emailYesNoHas your child's vision previously been tested? *YesNoIf Yes, when was the last exam? *If Yes, were glasses prescribed? *YesNoPlease list any family members who have had problems with vision:Why do you feel your child needs a visual evaluation?Have you noticed or does your child report any of the following?Eyes hurtingTired eyesEyes frequently reddenedFrequent eye rubbingFrequent blinkingLoosing place while readingconfusing of letters/wordsReversal of letters/wordsUse of finger as a marker when readingDifficulty recognising the same word on different pageDifficulty with memoryResponds better orally than by writingBlurry eyesPlease describe how often and when these problems occur:Does your child like school?YesNoPlease describe any specific school difficulties:Overall school work is:Above AverageAverageBelow AverageDoes your child like to read?A lotAverageAvoidsDoes your child read voluntarily?YesNoDoes your child read for fun?YesNoDo you feel your child is achieving to their potential?YesNoHave any other children in the family had learning problems?YesNoPlease describe to what extent:Please provide any additional information you feel would be helpful and/or important in our evaluation of your child: Click or drag a file to this area to upload. EmailSubmit
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