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798 Nicholson St
Fitzroy North, Victoria 3068
Primary School

Primary School

Questionnaire For Primary School Children

We ask you to take a few moments to complete this form.  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.

    • Parent's/ Carer’s Names and mobile numbers:

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

    A. Entering Complaint / Major Concern
    B. Visual History

    Previous Treatment:

    Family visual Difficulties. Are there any family members with visual difficulties?
    C.Development History

    Were the following developmental areas as expected?:

    D. General Health Behaviour

    Please select any condition that applies

    E.Educational Progress
    • What kind and for what (Occupational therapy/ speech therapy/ Educational Psychology)

    1. Please include any additional information, such as reports from other professionals, that will help us better understand your child.

    2. Please bring any spectacles that have been prescribed for your child to the consultation.

    PERFORMANCE CHECKLIST

    From questioning and observation of your child while he/she is doing VISUAL tasks, are any of the following behaviours or symptoms present. Record your observations with the:

    N Behaviour NEVER observed

    S Behaviour SOMETIMES observed.

    U Behaviour USUALLY observed.

    VISUAL FUNCTION:
    A. Signs of possible EYE FOCUS problems
    B. Signs of possible EYE TRACKING problems
    C.Signs of possible EYE TEAMING problems
    VISUAL INFORMATION PROCESSING:
    1.Signs of possible VISUAL - SPATIAL dysfunction
    2.Signs of possible VISUAL ANALYSIS dysfunction
    3.Signs of possible VISUAL - MOTOR integration dysfunction
    4.Signs of possible VISUAL - AUDITORY integration dysfunction
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