Langwarrin: 03 9776 7702 Email Us

Mornington: 03 5975 5720 Email Us

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New Child Questionnaire

New Child Questionnaire

Home New Child Questionnaire

Select Your Appointment Location*

Carrum DownsLangwarrinMornington

Personal Details

Gender*MaleFemale

Which Parent is the Primary Contact?Parent OneParent Two

Child’s Date of Birth*

Is your child covered by Private Health Insurance?YesNo

Do you have a Concession Card?YesNo

Medical History

Has your child had any serious illness or injury requiring hospitalisation?YesNo

Has your child a history of recurrent ear problems?YesNo

Have grommets been inserted?YesNo

Does your child suffer any other chronic or recurrent illness?YesNo

Does your child take any medications?YesNo

Has your child previously be assessed by any of the following?

Educational PsychologistAudiologistSpeech PathologistOccupational TherapistOphthalmologistPaediatrician

Has your child been diagnosed with any behavioural or learning dificulties?YesNo

Developmental History

Visual History

Has your child had a visual assessment?YesNo

Has your child had a school screening / testing for Dyslexia?YesNo

Were glasses prescribed?YesNo

Are glasses worn both at home and/or school?YesNo

Family History

Turned eyeLazy eyeMental illnessShort-sightedAnxietyAstigmatism

Observable behaviors possibly related to visual problems during home/school/outdoor environment

Covers or closes eyewhen readingComplains of words moving on the pageComplains of head achesComplains of double visionComplains of eyestrainInattentive / daydreamsPoor reading comprehensionLoses place when reading

Signs of Focusing Problems

Complains of blurred vision when readingComplains of blurred vision looking from desk to boardBecomes fatigued when readingAvoids small printComplains from copying from boardRubs eyes when concentratingShort attention when readingHolds books or any electrical devices close

Signs of Tracking Problems

Loses place oftenSkips words and lines oftenUses finger to keep placeShort attention span when reading

Signs of Visual Processing

Slow to learn letter / sound correspondenceSlow copying from board to book (takesmany looks)Doesn’t recognise the same word repeated on a pagePoor recall of visually presented materialTrouble with spelling and sight words vocabularySlow copying and completing worksheetsUntidy writingReverses letters / numbersMistakes words with similar beginningsCan respond orally but not in writingErases excessivelyTrouble learning maths and basic concepts of size

Signs of unusual glare sensitivity

Squints, closes one eye or has watery eyes in sunlightPrefers to read in dim illuminationComplains that the printed page appears “glary”

Education History

Does your child like school?YesNo

Does your child like reading?YesNo

Does the school consider your child to have a learning problem?YesNo

Does the school consider your child to have a discipline problem?YesNo

Is school workAverageBetter than average

Is your child having difficulty with:

ReadingWritingSpellingMaths

How did you hear about us?

Relative / Friend / Previous PatientYes

Facebook / social mediaPrint advertisementLocal shopping centre / passing byGP or other Health ProfessionalSchool

Future communication

Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email and sms?YesNo

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Book An Appointment

Langwarrin

230 Cranbourne-Frankston Road,
Shop 27A,
Langwarrin VIC 3910

[email protected]

03 9776 7702

Opening Hours

Mon - Fri : 09:00 AM - 05:30 PM
Sat: 9.00 AM - 1.00 PM
Sun: Closed

Mornington

Bentons Square Shop 25,
210 Dunns Road,
Mornington VIC 3931

[email protected]

03 5975 5720

Opening Hours

Mon - Fri : 09:00 AM - 05:30 PM
Sat: 9.00 AM - 2.00 PM
Sun: Closed

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Choose From 3 Locations

Langwarrin

230 Cranbourne-Frankston Road,
Shop 27A,
Langwarrin VIC 3910

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Mornington

Bentons Square Shop 25,
210 Dunns Road,
Mornington VIC 3931

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Carrum Downs

Carrum Downs Shopping CentreShop 18,
100 Hall Road,
Carrum Downs VIC 3201

Carrum Downs Eyecare