For new child patients, please fill in the form below Personal DetailsChild's Full Name(Required)Gender(Required) Male Female Child's Date of birth(Required) DD slash MM slash YYYY Parent/Guardian's Name(Required)Gender Male Female Address Street Address City State Postcode Parent/Guardian's Email(Required) Parent/Guardian's Mobile(Required)Child's Medicare number(Required)Card reference number(Required)Expiry Date(Required)Is your child covered by Private Health Insurance(Required) Yes No Private Health Fund ProviderGP's name(Required)GP's phone(Required)GP's addressPostcodeWhat's the reason for your visit today?(Required)Medical & Developmental HistoryHas your child previously been assessed by any of the following? Educational Psychologist Audiologist Speech Pathologist Occupational Therapist Ophthamologist Paediatrician Does your child currently wear glasses?(Required) Yes No Does your child have other health conditions we should be aware of?Was the pregnancy and birth free from complications? Yes No If No, provide detailsHow have the following developmental areas been progressing?General growth Good Fair Poor Walking Good Fair Poor Talking Good Fair Poor Hearing Good Fair Poor Social behaviour Good Fair Poor General coordination Good Fair Poor Name of schoolYear / LevelIs your child having difficulty with any of the following? Reading Writing Spelling Maths Behaviour If Yes, provide detailsHas your child repeated a grade? Yes No How would you rate your child's general present health? Good Fair Poor Please list any medications currently being taken by your childPlease detail important aspects of past health history: (Accidents, head/eye injuries, serious infections, high fevers, major surgeries etc)Eye HealthHas your child had a past visual examination? Yes No Previous visual examination date (approx)Reason for previous examinationResultsWhat were the previous treatments? Glasses/Contact Lenses Occlusion (eye patching) Vision Training Surgery Medication (e.g. eye drops or ointment) Details of previous treatmentsIs there any family history of “Eye Turn”, “Lazy Eye” or glasses? Yes No If yes, please describeHave other children in the family had visual issues?Do you observe any of the following? Unusual redness of eyes Unusual redness of lids Crusted lids Styes or sores on lids Excessive watering Present Health Unusual lid droopiness One eye turning IN or OUT with fatigue Excessive rubbing of eyes Frequent closing of one or both eyes Unusual clumsiness and bumping into objects If your child exhibits an “Eye Turn”, at what age was the “eye turn" first noticed?Is the turn always present or only occasionally?Could it be caused by any injury or illness? Yes No Does it turn” IN” or “OUT” In Out Is it always the same eye? Yes No Please bring any photos that show the turn to the appointment.Your AppointmentPlease bring to the examination any glasses that are presently worn by your child, or have been worn in the past. Please bring additional information, reports from other professionals etc. which you consider important to our understanding of your child.Do you need a detailed written report on the evaluation of your child’s eyesight and visual performance capabilities and optometric recommendations? Yes No Please list the names and addresses of people to whom you would like a copy of the report sent.How did you hear about us? Relative / Friend / Previous Patient Your GP Internet Search Our Website Facebook / Social Media Print Advert Other Future communicationAre you happy to receive occasional communications regarding eye health information and special offers by mail, email and sms? Yes No Thank you for entrusting us with your eyecarePrivacy Statement: Our practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide services to you. We may also use your personal contact information to send you information regarding eye health, eye care and eyewear, with your consent. By providing the information requested in the first three sections of this form we will be able to make an informed decision on how to best meet your eye care and eyewear needs. We may also need to provide some personal information to third party suppliers (such as providers of mail-out and electronic distribution services and 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. I have read and understood the privacy statement(Required) Yes CAPTCHA Δ
