Child’s name:Click here to enter text.
DOB:Click here to enter text.
Age: Click here to enter text.
School grade/year level: Click here to enter text.
Developmental history (please provide age, and details if appropriate):
Any complications during pregnancy/birth?Click here to enter text.
Was your child premature?Click here to enter text.
Birth weight?Click here to enter text.
Did your child crawl on hands and knees?Click here to enter text.
Did your child bottom shuffle?Click here to enter text.
When did your child walk?Click here to enter text.
When did your child say their first words?Click here to enter text.
When did you child speak in sentences?Click here to enter text.
Is your child right or left handed?Click here to enter text.
At what age did they definitely become right or left handed?Click here to enter text.
General health (please provide details if appropriate):
Does your child suffer from any chronic or recurrent illness? Click here to enter text.
Does your child have any allergies?Click here to enter text.
Does your child take any medications?Click here to enter text.
Has your child had any serious illness/injury requiring hospitalisation? Click here to enter text.
Has your child suffered an episode of high fever lasting 48hrs?Click here to enter text.
Does your child have a history of recurrent ear problems?Click here to enter text.
Have grommets (ear tubes) been inserted?Click here to enter text.
Does your child have any behavioural problems?Click here to enter text.
Has your child had speech or occupational therapy? Click here to enter text.
Is there any family history of:
-high/strong glasses prescriptions?Click here to enter text.
-amblyopia (lazy eye)?Click here to enter text.
-strabismus (squint/turned eye)?Click here to enter text.
-reading/writing/spelling difficulties?Click here to enter text.
Educational history (provide details where appropriate):
At what age did your child start school?Click here to enter text.
Has your child repeated a grade? If so, which grade?Click here to enter text.
Has your child’s progress at school been as expected?Click here to enter text.
Is your child having difficulty with:
-reading?Click here to enter text.
-writing?Click here to enter text.
-spelling?Click here to enter text.
-maths?Click here to enter text.
Has your child had any special education evaluations (eg. psychologist)?Click here to enter text.
What is your child’s:
-favourite subject?Click here to enter text.
-least favourite subject?Click here to enter text.
-easiest subject?Click here to enter text.
-hardest subject?Click here to enter text.
Does your child do any extracurricular activities (eg. sport, music)?Click here to enter text.
Visual history (please provide details where appropriate):
Does your child:
-cover/close on eye when reading?Click here to enter text.
-complain of words moving on the page?Click here to enter text.
-complain of eyestrain or headache?Click here to enter text.
-complain of double vision?Click here to enter text.
-complain of blurred vision when reading?Click here to enter text.
-complain of blurred vision when looking at the board?Click here to enter text.
-rub their eyes frequently?Click here to enter text.
-hold books close when reading? Click here to enter text.
-avoids near work (eg. reading, writing)? Click here to enter text.
-have poor reading comprehension?Click here to enter text.
-lose their place when reading?Click here to enter text.
-use their finger to keep their place when reading?Click here to enter text.
-skip words and lines often when reading?Click here to enter text.
-have a short attention span when reading?Click here to enter text.
-have trouble learning left & right?Click here to enter text.
-reverse letters & numbers (eg. b/d)?Click here to enter text.
-fail to recognise the same word in the next sentence?Click here to enter text.
-mistake words with similar beginnings/endings?Click here to enter text.
-have untidy writing?Click here to enter text.
-slow at copying & completing worksheets?Click here to enter text.
-trouble copying from board to book? Click here to enter text.
-poor spelling ability? Click here to enter text.
-respond well orally, but not in writing? Click here to enter text.
-have poor reading comprehension, but good comprehension when listening? Click here to enter text.
Any other comments?
Click here to enter text.
Thank you.
Eyecare Plus Clifton Hill
ABN: 48 167 009 458
302 Queens Parade, Clifton Hill VIC 3068
P: +61 3 9486 2055 | F: +61 3 9481 7990
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