Please complete this survey online so we can have your child’s file ready as soon as you arrive for your appointment.

Child's Title (required)

Child's Name (required)

Date of Birth (required)

---------- Parent's Info ----------

Address (required)

Home Ph. No

Work Ph. No

Mobile No

Email Address (required)

Medicare No

Parent's / Guardian's Name (required)

Referred by

---------- Child's status ----------




Please pick either card that you hold for your child
 Health Care Card Pension Card

Have your child had their eyes examined in the last two years?
 Yes No

Reason(s) for having your child’s eyes examined now

Does your child complain of
 Headaches Red, sore or watery eyes Blurry books or blackboard Words or letters running or moving Losing place or miss/skip words Uses finger to keep place Slow or poor copying from the blackboard Reverse letters or numbers Avoids reading

Detail important aspects of past medical history: (accidents, head/eye injuries, serious infections, high fevers, convulsions, surgeries etc)

Is your child’s present health
 Good Fair Poor

Are any medications being taken and for what?

Any complications before, during or after birth: (toxaemia, prolonged labour, traumatic birth, premature, low birth weight etc)

Was your child a constant crier, poor sleeper or feeder, over active?

Did your child
 Crawl on hands and knees Crawl by 10mths Walk by 12mths Walk unaided by 16mths Able to communicate with language by 18 ? 24mths

Reports will be sent back to you on your child’s results if any significant visual problems are detected. Who else would you like copies of reports sent to

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