Childs First Name *

Childs Last Name *

Date of birth

Mum’s Name:

Dad’s Name:

Teachers Name

Your Phone (Mobile Phone Preferably) *

Mobile No. (Only if primary phone is still landline)

Address *

City *

Postal code *

Child/StudentsMedicare Number *

Child/Students Medicare Reference Number *

Medicare Expiry Date *

Do you have private health insurance for optical extras? *

Yes

No

Private Health Fund Provider

GP

Other professionals

Main reason for bringing your child to our practice? *

Developmental History:

What Type Of Delivery Was The Birth?

Vaginal

C-section

Was The Baby Full Term Or Premature?

Full term

Premature

If premature how many weeks of gestation?

Was the baby a normal birth weight?

Yes

No

If no, what was the birth weight?

Were there any complications with the birth?

Yes

No

If yes, a brief explanation of the complication

Did the child meet developmental milestones at the right times?

Yes

No

When did they first crawl?

On time

Late

If late, when did they first crawl?

When did they first walk?

On time

Late

If late, when did they first walk?

Is there a history of middle ear infections?

Yes

No

Did the child require grommets?

Yes

No

Did the child have surgery to remove tonsils or adenoids?

Yes

No

Does the child have good fine/gross motor strength and coordination?

Yes

No

If no, what activities do they struggle with?

What hobbies or activities does the child like to engage in recreationally?

Does the child frequently trip, bump into things, or knock objects over unexpectedly?

Yes

No

If yes, what behaviours do you observe?

Medical History:

Has the child been diagnosed with any medical conditions?

Yes

No

If so, what have they been diagnosed with?

Does the child take any medications?

Yes

No

If yes, what medications do they take?

Does the child have any allergies?

Yes

No

If yes, what allergies does your child have?

When was the child’s last eye examination?

Where was this eye examination conducted?

Were any issues diagnosed by the last eye care practitioner?

Yes

No

If yes, what was diagnosed?

What treatments, if any, were recommended?

Family History

Is there a history of medical conditions such as diabetes, thyroid conditions, heart, or kidney disease in the family?

Yes

No

If yes, what conditions are within the family?

Is there a history of eye diseases such as macular degeneration, glaucoma, diabetic eye disease, cataract, or retinal detachment in the family?

Yes

No

If yes, what eye conditions are within the family?

Is there a family history of learning-related issues such as dyslexia, ADD, or Autism?

Yes

No

If yes, what was diagnosed (learning-related)?

Observable classroom behaviours that can possibly be related to vision problems. Please ‘tick’ next to any problems that seem to occur often for this child.

Visual Cognitive Problem-Solving Style

Rapid, poorly considered responses *

Yes

No

Tends to escape, withdraw or be passive in problems solving tasks *

Yes

No

Is your child underperforming academically relative to their ability? *

Yes

No

Does the child perform better with numeracy compared to literacy? *

Yes

No

When confronted with a challenging problem does your child respond impulsively, rushing the solution and not being worried about inaccuracies?

Yes

No

When confronted with a challenging problem does your child respond slowly, or not at all because they are worried about getting the answer wrong?

Yes

No

Does your child struggle with emotional regulation when they can't perform a task?

Yes

No

If yes, then how does this show up in your child?

Is your child willing to give new tasks a go, or are they too afraid to try?

Willing to try

Too afraid to try

Direction Concepts

Clumsy - poor general consideration *

Yes

No

Right and left confusion *

Yes

No

Reversals on letters, numbers or words (b/d) was/saw (12/21) *

Yes

No

Sequencing difficulty *

Yes

No

Visual Form Analysis

Repeatedly confuses similar beginnings and ending of words *

Yes

No

Whispers to self for reinforcement while reading silently *

Yes

No

Returns to ‘drawing with figures’ to decide likes and differences *

Yes

No

Can not recognise same word on page *

Yes

No

Trouble learning basic math concepts of size and magnitude *

Yes

No

Poor recall of visually presented material *

Yes

No

Eye-Hand Coordination

Must feel things to assist in any interpretation required *

Yes

No

Avoids eye-hand activities such as catching, ball play and tying laces or knots *

Yes

No

Uses hand or fingers to keep place on page *

Yes

No

Writes up or down hill on paper *

Yes

No

Eye Movement Control

Loses place often during reading and needs fingers or markers to keep place *

Yes

No

Frequently omits words *

Yes

No

Slow in completing set tasks *

Yes

No

Eye Focus Control

Squints or peers to look at fine detail *

Yes

No

Rubs eyes or blinks excessively after a short period of visual activity *

Yes

No

Excessively close or far eye to work distance *

Yes

No

Poor ability to sustain attention to fine detail tasks *

Yes

No

Difficulty copying from reference book or board *

Yes

No

Complains of blurring after reading or writing *

Yes

No

Eye Teaming

Complains of seeing double *

Yes

No

Squints, closes or covers one eye *

Yes

No

Tilts head extremely while working at desk *

Yes

No

Consistently shows gross postural deviations at desk activities *

Yes

No

Complains of print jumping, running together or moving *

Yes

No

Comprehension grows poorer as reading continues *

Yes

No

If The Form Does Not Submit, Please scroll back up to confirm all required fields are completed