Langwarrin:
03 9776 7702
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New Child Questionnaire
New Child Questionnaire
Home
New Child Questionnaire
Personal Details
Gender*
Male
Female
Which Parent is the Primary Contact?
Parent One
Parent Two
Child’s Date of Birth*
Is your child covered by Private Health Insurance?
Yes
No
Do you have a Concession Card?
Yes
No
Medical History
Has your child had any serious illness or injury requiring hospitalisation?
Yes
No
Has your child a history of recurrent ear problems?
Yes
No
Have grommets been inserted?
Yes
No
Does your child suffer any other chronic or recurrent illness?
Yes
No
Does your child take any medications?
Yes
No
Has your child previously be assessed by any of the following?
Educational Psychologist
Audiologist
Speech Pathologist
Occupational Therapist
Ophthalmologist
Paediatrician
Has your child been diagnosed with any behavioural or learning dificulties?
Yes
No
Developmental History
Visual History
Has your child had a visual assessment?
Yes
No
Has your child had a school screening / testing for Dyslexia?
Yes
No
Were glasses prescribed?
Yes
No
Are glasses worn both at home and/or school?
Yes
No
Family History
Turned eye
Lazy eye
Mental illness
Short-sighted
Anxiety
Astigmatism
Observable behaviors possibly related to visual problems during home/school/outdoor environment
Covers or closes eyewhen reading
Complains of words moving on the page
Complains of head aches
Complains of double vision
Complains of eyestrain
Inattentive / daydreams
Poor reading comprehension
Loses place when reading
Signs of Focusing Problems
Complains of blurred vision when reading
Complains of blurred vision looking from desk to board
Becomes fatigued when reading
Avoids small print
Complains from copying from board
Rubs eyes when concentrating
Short attention when reading
Holds books or any electrical devices close
Signs of Tracking Problems
Loses place often
Skips words and lines often
Uses finger to keep place
Short attention span when reading
Signs of Visual Processing
Slow to learn letter / sound correspondence
Slow copying from board to book (takesmany looks)
Doesn’t recognise the same word repeated on a page
Poor recall of visually presented material
Trouble with spelling and sight words vocabulary
Slow copying and completing worksheets
Untidy writing
Reverses letters / numbers
Mistakes words with similar beginnings
Can respond orally but not in writing
Erases excessively
Trouble learning maths and basic concepts of size
Signs of unusual glare sensitivity
Squints, closes one eye or has watery eyes in sunlight
Prefers to read in dim illumination
Complains that the printed page appears “glary”
Education History
Does your child like school?
Yes
No
Does your child like reading?
Yes
No
Does the school consider your child to have a learning problem?
Yes
No
Does the school consider your child to have a discipline problem?
Yes
No
Is school work
Average
Better than average
Is your child having difficulty with:
Reading
Writing
Spelling
Maths
How did you hear about us?
Relative / Friend / Previous Patient
Yes
Facebook / social media
Print advertisement
Local shopping centre / passing by
GP or other Health Professional
School
Future communication
Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email and sms?
Yes
No
