Completing this form online before your child’s appointment will allow us to prepare your child’s file prior to your arrival.

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 ----------

Grade

Teacher

School

Have your child had their eyes examined in the last two years?
YesNo

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

Does your child complain of
HeadachesRed, sore or watery eyesBlurry books or blackboardWords or letters running or movingLosing place or miss/skip wordsUses finger to keep placeSlow or poor copying from the blackboardReverse letters or numbersAvoids 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
GoodFairPoor

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 kneesCrawl by 10mthsWalk by 12mthsWalk unaided by 16mthsAble to communicate with language by 18 ‐ 24mths