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Child Questionnaire
Child Questionnaire
Child's Details
Full Name
(Required)
First
Middle
Last
Preferred Name
Date of Birth
(Required)
DD slash MM slash YYYY
Complete Medicare Number
(Required)
Medicare Card Position
(Required)
Medicare Expiry Date
(Required)
Do you have a private health fund?
(Required)
No
Yes
Private Health Fund Name
(Required)
Home Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Best contact Email
(Required)
Mobile Phone
School Attended
Grade/Year
Parent/Carer Details
Parent 1/Carer 1 Full Name
(Required)
First
Last
Parent 1/Carer 1 Mobile Phone
(Required)
Parent 1/Carer 1 Home Phone
Parent 2/Carer 2 Full Name
First
Last
Parent 1 / Carer 1 Occupation
(Required)
Parent 2/ Carer 2 Occupation
Does the child live with both parents?
(Required)
Yes
No
Visual History
Have they had any previous eye exams?
(Required)
No
Yes
When was the last exam?
DD slash MM slash YYYY
By whom?
Optometrist
Ophthalmologist
School Screening
Does one eye turn in or out?
(Required)
No
Yes
Which eye and which direction?
(Required)
Check all that apply
(Required)
Complains of eye strain
Complains of headache
Complaints of words moving on the page
Reverses letters and numbers
Rubs eyes
Loses place often
Reads the wrong line
Use finger to keep place
Short attention span when reading
Untidy writing
Trouble with spelling and sight word vocabulary
Seems to know material, but does poorly on written tests
Poor reading comprehension, yet good comprehension when listening
Erratic letter size/space
Slow copying and completing worksheets
Gets close to page when reading/writing
Difficulty copying from board to book
Tight pen grip / Presses heavily
Does the child dislike bright light, especially when outside?
(Required)
No
Yes
Who referred you to our practice?
(Required)
Child's present area of difficulty
Check all that apply
(Required)
Reading
Speech
Writing
Behaviour
Spelling
Delayed Development
Co-ordination
Concentration
Not applicable
Any other problems?
Birth History
Did mother have any of the following during pregnancy?
Medication
High blood pressure
Haemorrhage
Pregnancy difficult to maintain
Was labour?
(Required)
Vaginal
Caesarean
Describe any birth complications
Motor Skills
Motor Skills
(Required)
Yes
No
Not applicable
Do you consider you child has poor motor co-ordination?
Are they poor at ball games (catching/hitting) or at sports?
Do you consider they have poor balance?
Post Natal History
Was baby unsettled?
(Required)
No
Yes
Did baby have any sleeping difficulties in the first 6 months?
(Required)
No
Yes
Did the baby have any feeding difficulties in the first 6 months?
(Required)
No
Yes
Developmental History
Did you do tummy time on baby?
(Required)
No
Yes
Did they crawl on hands and knees?
(Required)
No
Yes
When did your child walk?
(Required)
Personality
Select all that apply
(Required)
Easy to anger
Impulsive
Short attention span
Lacks confidence
Tries hard
Overly sensitive emotionally
Hearing and Speech
Are they sensitive/upset by loud noises?
(Required)
No
Yes
Was development of speech considered abnormal?
(Required)
No
Yes
Has your child had a hearing test?
(Required)
No
Yes
General Development
Do they continue to have minor accidents (falls, bumps)?
(Required)
No
Yes
Do they get car sick?
(Required)
No
Yes
Do they touch everything especially when in new places?
(Required)
No
Yes
Medical History
Please check any conditions your child has suffered
Ear Infections
Frequent sore throats
Tonsilitis
Bronchitis
Night-time bed-wetting
High temperatures of unknown origin
Is your child on any medication?
(Required)
No
Yes
Others?
How is your child's general health?
(Required)
Excellent
Good
Fair
Poor
Any abnormal reactions to immunisations?
(Required)
No
Yes
Name of your GP
First
Last
Address of your GP
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Indicate any current mediations
Indicate any allergies
Any of the following?
Convulsions
Epilepsy
Chronic diarrhoea
Constipation
Head injury
Concussion
Broken Bones
Blood disorder
Lung disorder
Please describe the event, treatment and effect on the child in the days following the event
(Required)
Any other?
Schooling
Does your child like going to school?
(Required)
No
Yes
Not at school yet
Has your child repeated a grade?
(Required)
No
Yes
Not at school yet
Does your child have a behavioural problem at school?
(Required)
No
Yes
Not at school yet
Please describe in as much detail your child's current level of school achievement, or how far behind they may be in any school subjects:
(Required)
Has your child had any of the following:
Special Remedial Help (eg. Reading Recovery)
Psychological testing
Speech Therapy
Occupational Therapy
Please select this box to supply literacy and numeracy information
Please describe in as much detail any remedial help (school or home) that has been put in place for your child:
(Required)
How does your child get along with other classmates?
(Required)
Liked
A loner
A bully
Class clown
A leader
Not at school yet
How easy is it to get your child to engage in homework or reading / writing tasks?
(Required)
In what state does your child seem at the end of the school day?
(Required)
Tired
Irritable
Emotional
Is this the same on weekends and/or holidays?
(Required)
Outdoor Activities
Does your child spend time outside?
(Required)
No
Yes
How much?
(Required)
Describe the activities they like to do outside
(Required)
Electronic Devices
Does your child use devices?
(Required)
No
Yes
How much time daily?
(Required)
Are there any house rules in place?
(Required)
Does time on devices seem to affect your child's mood?
(Required)
Comments
This field is for validation purposes and should be left unchanged.
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Eye Examinations & Eye Health
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