Paediatric – Welcome to the Practice

PARENT/GUARDIAN

Name*

CHILD

Name*

SIGNS OF POOR VISUAL EFFICIENCY

Does your child show signs of/complain of:

Eyestrain
Double vision
Headaches
Excessive blinking
Blurred vision when reading
Glare sensitivity
Loses place when reading/skips words and lines often
Words moving on the page
Short attention span/becomes fatigued when reading
Poor reading comprehension
Rubs eyes when concentrating
Holds books/devices very close

SIGNS OF VISUAL PROCESSING DIFFICULTIES

Does your child show signs of/complain of:

Reversing letters and numbers
Not recognising the same word repeated on a page
Poor reading comprehension
Slow learning to read
Trouble with spelling and sight word vocabulary
Untidy writing
Mistakes words with similar beginnings
Can respond orally but not in writing
Slow copying from board to book

EDUCATION HISTORY

Name of school

Year level

Has your child's school progress been as expected for their ability?

Yes
No

Does your child have difficulty with:

Reading
Writing
Spelling
Maths

Has there been any remedial teaching?

Yes
No

Is there a history of learning problems in the family?*

Yes
No

Does your child have a history of delayed developmental milestones? (eg. speech/gross motor skills)*

Yes
No

Has your child repeated a grade?

Yes
No

Has your child had an assessment by an educational psychologist?*

Yes
No

Has your child had a speech pathology assessment/therapy?*

Yes
No

Has your child had an occupational therapist assessment/therapy?*

Yes
No

Has your child seen a paediatrician?*

Yes
No

Consent*

I acknowledge that I have read and agree to the privacy statement below*

PRIVACY STATEMENT: Our practice respects your privacy & will comply with the Privacy Act & Australian Privacy Principles when handling your personal
information. The information provided on this form helps us to make an informed decision on how to best meet your eyecare & eyewear needs. We may use your
personal contact information to send you information regarding eye health, eyecare and eyewear, with your consent. We may also need to provide some personal
information to third party suppliers (such as mail-out & electronic distribution services & eyewear suppliers) if and to the extent necessary for them to provide
the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please
contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy.

Paediatrics, Welcome to the Practice

To be completed on behalf of all children under 16 years of age.

If you are filling in details for multiple children please click “Add Another Child” after completing details for the first child.

PARENT/GUARDIAN

CHILD

SIGNS OF POOR VISUAL EFFICIENCY

SIGNS OF VISUAL PROCESSING DIFFICULTIES

EDUCATION HISTORY