• Pre-School Infant Toddler Vision Questionnaire

  • Thank you for carefully completing this questionnaire. The information you supplied will allow us to provide a more comprehensive evaluation and better meet your child's specific visual needs.

    If you have any questions, please contact our office at 02 9982 1039 prior to your appointment.

    We request a minimum of 48 hours' notice if you are unable to keep this appointment.

    PLEASE RETURN THIS FORM TO info@optimeyes.com.au 48 HOURS PRIOR TO THE APPPOINTMENT

  • GENERAL INFORMATION:

  • Gender*
  • Birth Date *
     - -
    2 digit day, 2 digit month, 4 digit year

  • (For Medicare claiming purposes)

  • Parents DOB*
     - -
    2 digit day, 2 digit month, 4 digit year

  • RESPONSIBLE PERSON INFORMATION:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you find us?
  • Format: (000) 000-0000.
  • Is your child especially afraid of doctors?

  • MEDICAL HISTORY

  • Format: (000) 000-0000.

  • If applicable

  • Format: (000) 000-0000.
  • Medications currently using, including vitamins and supplements
    Rows
  • List illnesses, bad falls/concussions, high fevers, etc.
    Rows
  • Is your child generally healthy?
  • Are there any chronic problems like ear infections, asthma, hay fever, allergies?
  • Other treatments/evaluations etc. Additional space available at the end of the questionnaire
    Rows

  • NUTRITIONAL INFORMATION

  • Current diet?
  • Does your child eat a good variety of fruit and vegetables?
  • Fish
  • Does your child: Like sweets or crave sweets
  • Medical History: Please mark yes/no on conditions that apply
    Rows

  • DEVELOPMENTAL HISTORY

  • Was the pregnancy full term?
  • Did the mother experience any health problem during the pregnancy?
  • Did the mother drink, smoke or take drugs during the pregnancy?
  • Was it a natural Birth?
  • Were there any complications before, during or immediately following delivery?
  • Were forceps used?
  • Was there ever any reason for concern over your child's general growth or development?
  • Has your child received any special developmental assistance?
  • How many hours daily does your child sleep? 

  • During  waking hours is/was your child

  • In a playpen?
  • For how long?
  • In a walker?
  • For how long?
  • In a seat?
  • For how long?

  • NUTRITIONAL INFORMATION

  • Are there any food allergies/sensitivities?
  • Activity Level
  • Are there periods of very high energy
  • Are there periods of very low energy?
  • Does your child: Like sweets  and/or  Crave sweets

  • FAMILY HISTORY

  • Family History: Please mark “Yes” / "No" on all conditions that apply and list the family member including cousins, aunts, uncles who has the following condition?
    Rows
  • Has your child's vision been previously evaluated?
  • Date of last evaluation
     - -
    2 digit day, 2 digit month, 4 digit year
  • Members of the family who have had visual attention and the reason
    Rows
  • Please check “yes” or “no” to the following observations and/or complaints as they relate to your child
    Rows
  • Does your child verbalise any problems/complaints about his/her eyes or vision?

  • PRE-SCHOOL/DAYCARE

    ******If your child attends preschool/daycare,  please fill out the following:

  • Does your child like pre-school?
  • Does your child like the teacher?
  • Compared to other children his/her age, do his/her general performance and social skills seem to be above
  • Does your child seem to be under tension at pre-school/day care?

  • CURRENT ABILITIES/BEHAVIOR

    Where appropriate, list the age at which your child could do the following: (some of these behaviours may not apply due to your child's chronological age).

  • Rows
  • Can your child identify colours?
  • Can your child identify numbers or letters?
  • Does your child like to draw/colour?
  • Is your child learning to read?
  • How is your child performing as compared to others his/her age?
  • Check the appropriate spaces if you have any concerns about the following behaviour(s) in your child

  • CONSENTS

    RELEASE OF INFORMATION

    IT IS OFTEN BENEFICIAL TO EXCHANGE INFORMATION AND DISCUSS YOUR CHILD'S RESULTS WITH HIS/HER SCHOOL AND OTHER PROFESSIONALS INVOLVED IN HIS/HER CARE. PLEASE SIGN BELOW TO AUTHORISE THIS EXCHANGE OF INFORMATION.

    I give my consent to make copies of my child's record and share any pertinent data from this exam to the school and other professionals. I also give my consent to provide any information to the health care providers

    This authorisation shall be considered valid throughout the duration of treatment.

  • Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • CONSENT TO PHOTOGRAPH

    PLEASE SIGN BELOW TO AUTHORISE.

    From time to time it may be necessary and useful to photograph your child in order to obtain records of eye movements, body movements and the like. The records are for the express use of the optometrist and therapist to gauge and monitor change and progress. They will not be provided to any external sources without your prior consent.

    I give my consent for my child to be photographed if clinically necessary.

  • Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • CONSENT TO MAKE BODY CONTACT

    PLEASE SIGN BELOW TO AUTHORISE.

    At times it may be necessary at times to guide you child with prompts which may require either the optometrist or therapist to gently touch your child. This will mostly be on the head, arm or leg and occasionally trunk or hips. This will usually be during therapy or during the assessments. We will always check with you first and you will always be present at these times.

    I give my consent for the optometrist or therapist to make body contact with my child if clinically necessary.

  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: