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Questionnaires
- Child Questionnaire
- Adults Questionnaire

Home
About Us
Our Services
- Adults
- Children
  - Vision Therapy
  - Children’s Vision
Eyewear
Contact Us
Book Now
Questionnaires
- Child Questionnaire
- Adults Questionnaire

Questionnaires

Child Questionnaire

Help us understand what brought your child to our practice, and how we can assist best.

Email

This field is for validation purposes and should be left unchanged.

Child Details

Name(Required)

First Middle Last

Preferred Name

Date of Birth(Required)

Complete Medicare Number(Required)

Medicare Card Position(Required)

Medicare Expiry Date(Required)

Do you have a private health fund?(Required)

Yes

No

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

What is your reason for visiting us?(Required)

Have they had any previous eye exams?(Required)

Yes

No

When was the last exam?(Required)

By whom?

Were glasses prescribed at this visit?(Required)

Yes

No

Does one eye turn in or out?(Required)

Yes

No

Which eye and which direction?(Required)

Check all that apply(Required)

Complains of eye strain

Complaints of words moving on the page

Rub eyes

Reads the wrong line

Short attention span when reading

Trouble with spelling and sight word vocabulary

Poor reading comprehension, yet good comprehension when listening

Slow copying and completing worksheets

Difficulty copying from board to book

Complaints of headache

Reverses letters and numbers

Loses place often

Use finger to keep place

Untidy writing

Tight pen grip/Presses heavily

Gets close to page when reading/writing

Seems to know material, but does poorly on written tests

Erratic letter size/spacing

Does the child dislike bright light, especially when outside?(Required)

Yes

No

Who referred you to our practice?(Required)

Child's present area of difficulty

Check all that apply(Required)

Reading

Writing

Spelling

Co-ordination

Speech

Behaviour

Delayed Development

Concentration

Not Applicable

Any other problems?

Birth History

Did mother have any of the following during pregnancy?(Required)

Medication

High blood pressure

Haomorrhage

Pregnancy difficult to maintain

Nil

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?
re they poor at ball games (catching/hitting) or at sports?
Do you consider they have poor balance?

Post Natal History

Was baby unsettled?(Required)

Yes

No

Did baby have any sleeping difficulties in the first 6 months?(Required)

Yes

No

Did the baby have any feeding difficulties in the first 6 months?(Required)

Yes

No

Developmental History

Did you do tummy time on baby?(Required)

Yes

No

Did they crawl on hands and knees?(Required)

Yes

No

When did your child walk?(Required)

Personality

Select all that apply(Required)

Easy to anger

Short attention span

Tries hard

Impulsive

Lacks confidence

Overly sensitive emotionally

Hearing and Speech

Are they sensitive/upset by loud noises?(Required)

Yes

No

Was development of speech considered abnormal?(Required)

Yes

No

Has your child had a hearing test?(Required)

Yes

No

General Development

Do they continue to have minor accidents (falls, bumps)?(Required)

Yes

No

Do they get car sick?(Required)

Yes

No

Do they touch everything especially when in new places?(Required)

Yes

No

Medical History

Please check any conditions your child has suffered

Ear infections

Frequent sore throats

Tonsilitis

Bronchitis

Night-time bed-wetting (if yes please provide ages)

High temperatures of unknown origin

Is your child on any medication?(Required)

Yes

No

Anything else you would like us to know:

How is your child's general health?(Required)

Excellent

Good

Fair

Poor

Any abnormal reactions to immunisations?(Required)

Yes

No

Name of your GP(Required)

First Last

Address of your GP

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Indicate any current medications

Indicate any allergies

Any of the following?

Convulsions

Chronic diarrhoea

Head Injury

Broken Bones

Lung disorder

Epilepsy

Constipation

Concussion

Blood disorder

Any other?

Schooling

Does your child like going to school?(Required)

Yes

No

Not at school yet

Has your child repeated a grade?(Required)

Yes

No

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)

Does your child have a behavioural problem at school?(Required)

Yes

No

Not at school yet

Has your child had any of the following:(Required)

Special Remedial Help (eg. Reading Recovery)

Psychological testing

Speech Therapy

Occupational Therapy

None

Please select this option to supply literacy and numeracy information in the next box

Literacy/Numeracy information:(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

Fine/Relaxed

Is it the same on weekends and/or holidays?(Required)

Outdoor Activities

Does your child spend time outside?(Required)

Yes

No

How much?(Required)

Describe the activities they like to do outside(Required)

Electronic Devices

Does your child use devices?(Required)

Yes

No

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)

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8:30am – 5:00pm

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245 King St, Newcastle NSW 2300
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