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Secondary School

WELCOME TO FITZROY NORTH EYE CENTRE

We ask you to take a few moments to complete our questionnaire for Secondary School Students.  The purpose of collecting this information is to assist us in providing your child with the highest quality eye-care.  All information will be treated in the strictest confidence in accordance with the Privacy Act. As you complete this history questionnaire we hope that you will recognize the thoroughness with which your child’s vision will be considered. The examination will take up enough time to permit a very complete investigation.

Name(Required)
DD slash MM slash YYYY
Home Address(Required)
Parent/Carer
Parent/Carer
Please tick here to give us permission to contact Medicare if we need to clarify information regarding item numbers

Educational Progress

Coordination

Coordination

Visual History

Previous Visual Training/ Therapy?
Spectacles
Contact Lenses
Has your child ever suffered a concussion or head trauma?
Signs of Visual Skills Problems
Signs of Focusing Problems
Signs of Visual Processing Disorders