optimeyes - High School Questionnaire

High School Age Vision Questionnaire
Please fill out this questionnaire carefully. THANK YOU
GENERAL INFORMATION:
Child's Full Name

First NameLast Name
Gender
Birth Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
School Year
Name of School
Name of classroom/Class Coordinator
Private Health Fund Name
Private Health fund membership number
Ref #
the number next to your name
Medicare #
10 digit number
Ref #
the number next to your name
Exp Date
(For Medicare claiming purposes)
Parent's Ref #
Parent's Name
Parent's DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
RESPONSIBLE PERSON INFORMATION:
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Parent 1 Name
Parent 1 Mobile Phone
Format: (000) 000-0000.
Parent 1 Email Address
Parent 2 Name
Parent 2 Mobile Phone
Format: (000) 000-0000.
Parent 2 Email Address
Primary Reason for visit
How did you find us?

Other
Word of mouth - Name
Professional referral - Name
Phone
Format: (000) 000-0000.
Are you especially afraid of doctors?
MEDICAL HISTORY
GP's Name
Phone Number
Format: (000) 000-0000.
GP's Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PAEDIATRICIAN
If applicable
Pediatrician’s Name
Phone Number
Format: (000) 000-0000.
Pediatrician’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medications currently using, including vitamins and supplements

Rows	Medications	Condition
1
2
3
4
5
6

List illnesses, bad falls, high fevers, etc.

Rows	Illness	Age	Severity (Mild- Severe)	Complications
1
2
3
4
5

Is your child generally healthy?
If no, explain
Are there any chronic problems like ear infections, asthma, hay fever, allergies?
If yes, please list
Has a neurological evaluation been performed?
If yes, by whom?
Results and recommendations
Has a psychological evaluation been performed?
If yes, by whom?
Result sand recommendations
Has an occupational therapy evaluation been performed?
If yes, by whom?
Results and recommendations
Has a speech therapy evaluation been performed?
If yes, by whom?
Results and recommendations

Other treatments/evaluations etc.

Rows	Yes/No	By Whom	Results / Recommendations
Neurological
Psychological
Occupational Therapy
Speech Therapy
Other

NUTRITIONAL INFORMATION
Current diet?
Does your child: Like sweets or crave sweets
Is your child active (with respect to behavior and not sports)?
If yes is he/she moderately or extremely active? TELEVISION VIEWING/LEISURE TIME ACTIVITIES
Does child watch TV?
How much?
How often?
Viewing distance?
Does your child spend time using computer/tablet/video games?
If yes, how much time?
How often?
Viewing distance?
What other activities occupy your child’s leisure time?
How much time does your child spend outdoors on a daily basis

Medical History: Please mark yes/no on conditions that apply

Rows	Yes/No
Strabismus (crossed eye)
Amblyopia (lazy eye)
Learning Disability
Dyslexia.
ADD/ADHD
Asperger’s Syndrome/Autism
Epilepsy/Seizure
Chromosomal Imbalance.
Diabetes.
High Blood Pressure.
Glaucoma.
Thyroid Condition
Multiple Sclerosis
Brain Tumor/Brain Injury

Other. Please list
Allergies to foods or medications
If yes, please list

Family History: Please mark “Yes” / "No" on all conditions that apply and list the family member who has the following condition?

Rows	Yes / No	Family Member/s
Myopia (near/short sighted) - distance vision is poor
Hyperopia (far/long sighted) - near vision is poor
Presbyopia - age related reduced near vision
Strabismus (crossed eye)
Amblyopia (lazy eye)
Learning Disability
Dyslexia
ADD/ADHD
Asperger’s Syndrome/Autism
Epilepsy/Seizure
Chromosomal Imbalance
Diabetes
High Blood Pressure
Glaucoma
Multiple Sclerosis
Other

DEVELOPMENTAL HISTORY
Was there ever any reason for concern over your child's general growth or development?
If yes, explain

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.
Signature
Date

DayMonthYear
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.
Signature
Date

DayMonthYear
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.
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
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 priorto your appointment. We request a minimum of 48 hours’ notice if you are unable to keep this appointment.
Should be Empty:

Rows	Yes / No	If yes, when and how often?
Headaches
Blurred vision / focus goes in and out
Double vision
Eyes hurt
Eyes tired
Words move around on the page
Motion sickness / car sickness
Dizziness

Rows	Yes / No	If yes, when and how often?
Eyes frequently reddened
Frequent eye rubbing
Frequent sties
Frowning
Bothered by light
Frequent blinking
Closing or covering one eye
Difficulty seeing distant objects
Head close to paper when reading or writing
Avoids reading
Prefers being read to
Tilts head when reading
Tilts head when writing
Moves head when reading
Skips, rereads or omits words
Loses place while reading
Vocalizes when reading silently
Reads slowly
Uses finger as a marker
Poor reading comprehension
Comprehension decreases over time
Writes or prints poorly
Writes neatly but slowly
Tires easily
Difficulty copying from board

Rows	Above average	Average	Below average
1
2
3
4
5
6

High School Age Vision Questionnaire

Please fill out this questionnaire carefully. THANK YOU

GENERAL INFORMATION:

RESPONSIBLE PERSON INFORMATION:

MEDICAL HISTORY

PAEDIATRICIAN

NUTRITIONAL INFORMATION

DEVELOPMENTAL HISTORY

OCULAR HISTORY

SCHOOL

GENERAL BEHAVIOR

FAMILY AND HOME

CONSENTS

RELEASE OF INFORMATION

CONSENT TO PHOTOGRAPH

PLEASE SIGN BELOW TO AUTHORISE.

CONSENT TO MAKE BODY CONTACT

PLEASE SIGN BELOW TO AUTHORISE.