Welcome to the practice

Are you submitting this form for yourself or on behalf of a child?

I'm making an appointment for:*

Myself
A child (under 16yo)

Date of your appointment*

YOUR DETAILS

Name*

Title First Name Surname Known As

Sex assigned at birth

Preferred pronouns

Address*

Address Suburb State Postcode

Please do not put PO Box address.

Phone*

Date of Birth*

Email*

Medicare No.

Reference No.*

Expiry*

Private health insurance? If yes, which provider?

What is the main reason for your visit today?*

Occupation

Sports/Hobbies

CHILD

Name*

Sex assigned at birth

Preferred pronouns

Date of Birth*

Medicare No.

Reference No.

Expiry*

PARENT/GUARDIAN

Name*

Title First Name Surname Known As

Date of Birth*

Phone*

Address*

Address Suburb State Postcode

Please do not put PO Box address

Email*

Medicare Reference No.*

Private health insurance? If yes, which provider?

What is the main reason for your visit today?*

SIGNS OF POOR VISUAL EFFICIENCY

Does your child show signs of/complain of:

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

MEDICAL HISTORY

Short sightedness

You
Relative

Long sightedness

You
Relative

Lazy eye or squint

You
Relative

Colour vision problem

You
Relative

Eye diseases

You
Relative

Eye injury

You
Relative

Eye surgery

You
Relative

Blindness

You
Relative

Cataracts

You
Relative

Glaucoma

You
Relative

Diabetes

You
Relative

High blood pressure

You
Relative

Heart problems

You
Relative

Allergies/asthma/skin problems

You
Relative

Cancer

You
Relative

Arthritis

You
Relative

Nerve problems

You
Relative

Autism spectrum disorder

You
Relative

Head injury (including concussion)

You
Relative

Other

CURRENT MEDICATIONS

List all medications

Name*

GP Name GP Clinic/Suburb

DO YOU HAVE, OR ARE YOU INTERESTED IN HAVING:

Glasses

HAVE
INTERESTED IN

Contact lenses

HAVE
INTERESTED IN

A spare pair of glasses

HAVE
INTERESTED IN

Sunglasses

HAVE
INTERESTED IN

Prescription sunglasses

HAVE
INTERESTED IN

Sleep contacts/Ortho K

HAVE
INTERESTED IN

DO YOU EXPERIENCE...

Do you experience

HOW DID YOU HEAR ABOUT US?

Friend/relative (Name)

Internet Search

Doctor

Other/Name of referrer

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

Please complete the questionnaire before coming to your appointment.

PLEASE NOTE:

For children under the age of 16, we will require a parent or guardian to submit the form on their behalf.

When you have completed this form please press “Submit” if you’d like to make another appointment please fill in two forms, one per child.

Are you submitting this form for yourself or on behalf of a child?

YOUR DETAILS

CHILD

PARENT/GUARDIAN

SIGNS OF POOR VISUAL EFFICIENCY

SIGNS OF VISUAL PROCESSING DIFFICULTIES

EDUCATION HISTORY

MEDICAL HISTORY

CURRENT MEDICATIONS

DO YOU HAVE, OR ARE YOU INTERESTED IN HAVING:

DO YOU EXPERIENCE...

HOW DID YOU HEAR ABOUT US?