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Home » Patient Forms » Pre School

Pre School

WELCOME TO FITZROY NORTH EYE CENTRE

We ask you to take a few moments to complete our Pre-School Questionnaire.  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. It is desirable to have both parents present during the examination when possible.

Name(Required)
Date of Birth(Required)
Home Address(Required)
Name(Required)
Please tick here to give us permission to contact Medicare if we need to clarify information regarding item numbers
One of our consultation rooms is upstairs, can you manage stairs?

A. Entering Complaint / Major Concern:

B. Visual History:

Previous Treatment:
Family visual Difficulties. Are there any family members with visual difficulties?
If Yes. What?

C. Observations:

Do you notice any of the following? Please tick box

D. Development History

Was pregnancy and birth free from complications?
Is your child right or left handed?
Have the following development areas been progressing as you would expect?
Milestones

E. General Health

Has your child ever suffered a concussion or head trauma?
Are any medications currently being taken?
Has the child ever experienced severe illness, fever, injury or physical impairment?
Please tick any condition that applies
NOTE:

1. Please bring any additional information, such as reports from other professionals (speech therapist, occupational therapist, school counsellor), that will help us better understand your child.

2. Please bring any spectacles that have been prescribed for your child to the consultation. If unavailable and you have the prescription please bring this in.

Thank you