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798 Nicholson St
Fitzroy North, Victoria 3068
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.

    Please sign here to give us permission to contact Medicare if we need to clarify information regarding item numbers:

    A.Entering Complaint / Major Concern:
    • Briefly detail your main concern

    • Who first recommended our practice to you:

    B.Visual History:

    Previous Treatment:

    C.Observations:
    D. Development History

    Have the following development areas been progressing as you would expect?

    E. General Health
    • Please describe your child's present health/ medical conditions:

    NOTE:

    1. Please include 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

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