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798 Nicholson St
Fitzroy North, Victoria 3068
Secondary School

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.

    • Concerns about vision

    Educational Progress
    • Non necessary time on small screens per day:

    Visual History

    Signs of Visual Skills Problems

    Signs of Focusing Problems

    Signs of Visual Processing Disorders

    • Any other comments:

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