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Child Form

1. Personal Details

Sex

Child’s First Name

Child’s Surname

Date of birth

Parent/Guardian’s name

Address

Suburb

Home Phone

Parent/Guardian’s mobile

Parent/Guardian’s email

Is your child covered by private health insurance?

If so which provider?

What is the main reason for your visit?

2. Medical History

Has your child previously been assessed by any of the following?

Educational Psychologist

Yes

Audiologist

Yes

Speech Pathologist

Yes

Occupational Therapist

Yes

Ophthamologist

Yes

Paediatrician

Yes

Has your child been diagnosed with any behavioural or learning difficulties?

Yes

If yes, please specify:

Does your child currently wear glasses?

Yes

Does your child have other health conditions we should be aware of?

Please list any medications your child is currently taking:

3. Education

Name of school

Year level

Is your child having difficulty with any of the following?

Reading

Yes

Spelling

Yes

Writing

Yes

Maths

Yes

Behaviour

Yes

Has your child repeated a grade?

4. Birth and Development

Did you experience any complications during birth?

If yes, please specify:

At what age did your child start to crawl?

5. How did you hear about us?

Please select

Your GP Walking past School Screening School teacher Facebook/social media Internet search/our website Other

Or a relative/friend/previous patient

6. Future Communication

Are you happy to receive occasional communications including appointment reminders and information on eyecare and eyewear via mail, email and sms?

Please select

Yes No