Caring for the eyes of Mackay since 1952
103 Alfred St
Mackay, QLD 4740
Phone Today:
(07) 4957 3066
Email Us:
reception@bucktodd.com.au
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Parent Pre-examination Questionnaire
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Parent Pre-Exam Test Page
Home
Parent Pre-Exam Test Page
Evaluation:
*
Yes, I would like a full comprehensive evaluation for learning difficulties.
Thanks, I am happy with the standard evaluation.
I would like to receive a vision report ($60)
*
Yes
No
Child's Name:
*
First
Middle
Last
Year Level
Kindergarten
Prep
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth:
*
DD slash MM slash YYYY
Gender:
*
Select
Male
Female
School:
Select
Alligator Creek State School
Andergrove State School
Beaconsfield State School
Bloomsbury State School
Bucasia State School
Carlisle Christian College
Chelona State School
Coningsby State School
Dundula State School
Eimeo Road State School
Emmanuel Catholic Primary School
Eton North State School
Eton State School
Eungella State School
Farleigh State School
Finch Hatton State School
Fitzgerald State School
Gargett State School
Glenella State School
Hampden State School
Homebush State School
Koumala State School
Mackay Central State School
Mackay Christian College
Mackay North State School
Mackay West State School
MacKillop Catholic Primary School
Marian State School
Mirani State School
Northview State School
Oakenden State School
Pindi Pindi State School
Pinnacle State School
Sarina State School
Seaforth State School
Slade Point State School
St Anne's Catholic Primary School
St Francis Xavier Catholic Primary School
St John's Catholic School
St Joseph's Catholic Primary School
St Mary's Catholic Primary School
Swayneville State School
Victoria Park State School
Walkerston State School
Whitsunday Anglican School
Other
Type the name of your School:
Teacher:
Paediatrician / Doctor:
Mother’s Name:
Father’s Name:
Email Address:
*
Address:
*
Street Address
Suburb
State
Post Code
Home Phone:
Work Phone:
Mobile:
*
Whom may we thank for recommending you consult us?
What is the primary reason for today’s examination?
1. Previous Eye Examinations
a) Has your child had previous eye examinations?
Select
Yes
No
Previous Provider:
Select
Dr Ieuan Rees (Optometrist)
Dr Ruth Stewart (Optometrist)
Dr Natalie Rokic (Optometrist)
Dr Jessica Saro (Optometrist)
Dr Brad Kirkwood (Optometrist)
Dr Andre Horak (Ophthalmologist)
Dr Chris Hornsby (Ophthalmologist)
Dr David Denman (Ophthalmologist)
Dr Ed Boets (Ophthalmologist)
Dr Joe Li (Ophthalmologist)
Buck & Todd
Eye Q
Eyes-R-Us
Laubman and Pank
OPSM
Pioneer Eye Centre
Specsavers
Vision Eye Institute
Westfund
Other
Please indicate who your previous provider was:
Was your child diagnosed with any of the following eye related problems?
Accommodative infacility
Accommodative insufficiency
Accommodative dysfunction
Amblyopia (lazy eye)
Astigmatism
Brown’s tendon sheath syndrome
Cataract
Conjunctivitis
Convergence excess
Convergence infacility
Convergence insufficiency
Dry eye
Duane’s retraction syndrome
Esotropia
Exotropia
Intermittent esotropia
Intermittent exotropia
Focussing problems
Glaucoma
Hyperopia (long-sightedness)
Iritis
Irlen-Meares Syndrome
Keratoconus
Myopia (short-sightedness)
Ocular-motor dysfunction
Strabismus
Uveitis
Visual perception difficulties
Visual processing disorder
Jaw Winking / Marcus Gunn Jaw Winking
b) What was the treatment prescribed:
Glasses
Contact lenses
Eye exercises
Orthokeratology
Surgery
Eye-drops
Vision Therapy
Irlen Lenses
None
Other
If other is selected please specify:
Are glasses / contact lenses still being used?
Select
Yes
No
Sometimes
For what tasks are they used?
Full time wear
Distance tasks
Reading
Computer
Ipad
Classroom
Television
Was the treatment helpful? (0-5)
0 = Not helpful & gave headaches, 5 = Very helpful
c) How is your child performing academically compared to age?
1 (Below Average)
2 (Slightly Below Average)
3 (Average)
4 (Slightly Above Average)
5 (Above Average)
Not sure
d) How well developed is your child’s spoken vocabulary?
1 (Below Average)
2 (Slightly Below Average)
3 (Average)
4 (Slightly Above Average)
5 (Above Average)
Not sure
2. Have you noticed your child experiencing any of the following problems whilst reading?
Avoidance of near work reading
Holds reading unusually close
Squints / blinks a lot
Blurred vision
Holds reading unusually far away
Tilts head or closes one eye
Experience confusion with letters
Letters / words appear to move or float
Tires easily
Short attention span
Experience confusion with words
Loses place whilst reading
Using a finger as a marker
Experience double vision (sees 2 when there is only one)
Moves head whilst reading
Words become blurred
Nausea when performing visual tasks
Words fade or disappear
Eyelid droops
Poor reading comprehension
Words jump around
Eyes hurt or get tired
Reads slowly
Words shrink or enlarge
Faint colours appear around words
Rubs eyes excessively
Words run together
Has poor ability to remember what is read
Skips or repeats the lines
Other
None of the above
If other is selected please specify:
3. Does your child have or report any of the following?
An eye which turns in
Has red encrusted eyelids
Tendency to flick at objects in front of their face
An eye which turns out
Itchy eyes
Tired eyes
Burning eyes
Sore eyes
Watery eyes
Frequently red eyes
Not sure
4. Does your child tend to suffer?
Reversal of letters
Motion sickness
Difficulty copying from the board
Reversal of words
Tendency to be clumsy
Poor attention
Sensitivity to light
Difficulty changing focus from distance to near
Poor tracking
Sensitivity to noise
None of the above
5. If your child suffers tired or sore eyes, which of the following may make them tired or sore?
Reading for a long time
Reading for a short time
Looking in the distance for a long time
Looking in the distance for a short time
Other
Not applicable
If other is selected please specify:
6. Sleep Patterns: Please indicate if your child has or is
A family history of sleep apnoea
Irritable during the day
A mouth open sleeper
Loud Breathing or snoring during sleep
Tired during the day / requiring daytime sleep
A restless sleeper (frequently waking)
Hyperactive during the day
None of the above
7. Are you concerned your child may be on the Autism Spectrum
Yes
No (Will skip to question 11)
8. Do you already have a diagnosis: If so what?
ADD (Attention Deficit Disorder)
ADHD (Attention Deficit Hyperactivity Disorder)
Anxiety
Asperger
Auditory Processing Disorder
Autism Spectrum Disorder
Depression
Development Co-ordination Disorder
Gifted
High functioning ADHD
OCD (obsessive-compulsive disorder)
ODD (Oppositional Defiant Disorder)
Sensory Integration Disorder
Specific Learning Disorder
Tourettes Syndrome
No diagnosis
9. On a scale of 1 through to 5 how would you rank your child for the following categories?
a) Speech
1 (Non-speaking)
2
3
4
5 (Typical speech)
b) Social Skills
1 (Poor)
2
3
4
5 (Normal)
c) Intelligence
1 (Low)
2
3
4
5 (High)
d) Special skills
1 (None)
2
3
4
5 (Excess of normal in a limited field)
e) How would you rate your childs sensitivity / need to touch - need to not be touched
Hyposensitive wherein he/she seeks physical contact (hugs)
Hyposensitive wherein he/she feels the need for physical contact
Hyposensitive wherein he/she likes to touch and have some physical contact
Normal
Hypersensitive wherein he/she avoids physical contact but allows some closeness
Hypersensitive wherein he/she avoids most physical contact
Hypersensitive wherein he/she shuns physical contact
10. If your child has special skills in what field are they?
Music
Mechanical
Routines
Numeracy
Spatial
Attention to detail
Artistic
Perfectionist
Other
No special skills
If other is selected please specify:
11. Please list all of the following
a) Concerns about your child's academic abilities
Reading
Writing
Spelling
Mathematics
Other
If other is selected please specify:
b) Your child's strengths:
c) Sports your child plays:
AFL
Auskick
baseball
basketball
BMX
cooking
cricket
dancing
fishing
football
golf
gymnastics
hockey
Judo
karate
lego
netball
rugby league
rugby union
soccer
softball
swimming
tennis
Touch football
working with dad
other
Please specify the other sport your child plays
d) Musical instruments your child plays:
bass guitar
cello
clarinet
cymbals
double bass
drums
flute
French horn
guitar
harp
oboe
percussion
piano
piccolo
recorder
saxophone
triangle
trombone
trumpet
tuba
viola
violin
Xylophone
Other
None
Please specify the other instrument your child plays
12. Does your child currently or have they previously had any of the following systemic health issues?
Asthma
Breathing problems
Hay-fever
Concussion
Developmental delay
Epilepsy
Fits or convulsions
Head injury
Neurological problems
Psychiatric / social problems
Musculoskeletal problem
Poor general co-ordination
Ear, nose and throat problems
Recurrent ear infections
Eye surgery
Hospitalisations
Gastro-intestinal problems
Surgery
Other
None of the above
If other is selected please specify:
a. Has your child had grommets inserted in their ears?
*
Please select
Yes
No
b. Has your child had their tonsils removed?
*
Please select
Yes
No
c. Has your child had their adenoids removed?
*
Please select
Yes
No
13. Has your child had any other form of assessment / assistance?
Central auditory processing
Chiropractic
Irlen / coloured lenses
Coloured overlays
Educational assistance
Learning support
Occupational therapy
Physiotherapy
Speech therapy
Vision therapy
Other
None of the above
If other is selected please specify:
14. Does your child take any medication?
Chlorpheniramine
Phenergan
Phenylephrine
Amoxicillin / Clavulanat
Azithromycin
Cefdinir
Cephalexin
Adderall
Adderall XR
Concertax
Daytrana
Metadate
Methylin
Ritalin
Vyvanse
Fluvoxamine
Intuniv
Respiridone
Dextromethorphan
Albuterol
Fluticasone
Nasonex nasal spray
Prednisolone sodium phosphate
Pulmicort
Rhinocort
Ibuprofen
Insulin
Reglan
Other
None of the above
If other is selected please specify:
15. a) Family History: Are there any direct family members or relatives with a history of the following?
Amblyopia (lazy eye)
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Glaucoma
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Macula Degeneration
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Myopia
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Retinitis Pigmentosa
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Strabismus (turned eye)
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Diabetes
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Epilepsy
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Heart Disease
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
High blood pressure
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Migraine
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Stroke
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Learning issues
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
Dyslexia
Please indicate which family members have a history:
*
Brother
Sister
Father
Mother
Aunt (Paternal)
Aunt (Maternal)
Uncle (Paternal)
Uncle (Maternal)
Grandmother (Paternal)
Grandmother (Maternal)
Grandfather (Paternal)
Grandfather (Maternal)
Multiple relatives on paternal side
Multiple relatives on maternal side
Relatives on both sides
Not sure
16. Developmental History:
a) Length of pregnancy
Please select
21 weeks
22 weeks
23 weeks
24 weeks
25 weeks
26 weeks
27 weeks
28 weeks
29 weeks
30 weeks
31 weeks
32 weeks
33 weeks
34 weeks
35 weeks
36 weeks
37 weeks
38 weeks
39 weeks
40 weeks
41 weeks
42 weeks
43 weeks
b) Type of delivery:
Natural
Forceps
Caesarean
c) APGAR score at birth:
select
0
1
2
3
4
5
6
7
8
9
10
Unknown
d) APGAR score at 10 minutes:
select
0
1
2
3
4
5
6
7
8
9
10
Unknown
e) Were there any complications? What were they?
Pre-eclampsia
Asphyxia
Cerebral palsy
Chord prolapse
Meconium aspiration
Pneumonia
Dislocated shoulder
Foetal distress
Gestational diabetes
Hypertension
Other
None
Please specify what other complication:
f) Child birth weight
Please Select
700 grams / 1 pound 9 ounces
725 grams / 1 pound 10 ounces
750 grams / 1 pound 10 ounces
775 grams / 1 pound 11 ounces
800 grams / 1 pound 12 ounces
825 grams / 1 pound 13 ounces
850 grams / 1 pound 14 ounces
875 grams / 1 pound 15 ounces
900 grams / 2 pounds
925 grams / 2 pounds 1 ounces
950 grams / 2 pounds 2 ounces
975 grams / 2 pounds 2 ounces
1000 grams / 2 pounds 3 ounces
1025 grams / 2 pounds 4 ounces
1050 grams / 2 pounds 5 ounces
1075 grams / 2 pounds 6 ounces
1100 grams / 2 pounds 7 ounces
1125 grams / 2 pounds 8 ounces
1150 grams / 2 pounds 9 ounces
1175 grams / 2 pounds 9 ounces
1200 grams / 2 pounds 10 ounces
1225 grams / 2 pounds 11 ounces
1250 grams / 2 pounds 12 ounces
1275 grams / 2 pounds 13 ounces
1300 grams / 2 pounds 14 ounces
1325 grams / 2 pounds 15 ounces
1350 grams / 2 pounds 16 ounces
1375 grams / 3 pounds 1 ounces
1400 grams / 3 pounds 1 ounces
1425 grams / 3 pounds 2 ounces
1450 grams / 3 pounds 3 ounces
1475 grams / 3 pounds 4 ounces
1500 grams / 3 pounds 5 ounces
1525 grams / 3 pounds 6 ounces
1550 grams / 3 pounds 7 ounces
1575 grams / 3 pounds 8 ounces
1600 grams / 3 pounds 8 ounces
1625 grams / 3 pounds 9 ounces
1650 grams / 3 pounds 10 ounces
1675 grams / 3 pounds 11 ounces
1700 grams / 3 pounds 12 ounces
1725 grams / 3 pounds 13 ounces
1750 grams / 3 pounds 14 ounces
1775 grams / 3 pounds 15 ounces
1800 grams / 3 pounds 15 ounces
1825 grams / 4 pounds
1850 grams / 4 pounds 1 ounces
1875 grams / 4 pounds 2 ounces
1900 grams / 4 pounds 3 ounces
1925 grams / 4 pounds 4 ounces
1950 grams / 4 pounds 5 ounces
1975 grams / 4 pounds 6 ounces
2000 grams / 4 pounds 7 ounces
2025 grams / 4 pounds 7 ounces
2050 grams / 4 pounds 8 ounces
2075 grams / 4 pounds 9 ounces
2100 grams / 4 pounds 10 ounces
2125 grams / 4 pounds 11 ounces
2150 grams / 4 pounds 12 ounces
2175 grams / 4 pounds 13 ounces
2200 grams / 4 pounds 14 ounces
2225 grams / 4 pounds 14 ounces
2250 grams / 4 pounds 15 ounces
2275 grams / 5 pounds
2300 grams / 5 pounds 1 ounces
2325 grams / 5 pounds 2 ounces
2350 grams / 5 pounds 3 ounces
2375 grams / 5 pounds 4 ounces
2400 grams / 5 pounds 5 ounces
2425 grams / 5 pounds 6 ounces
2450 grams / 5 pounds 6 ounces
2475 grams / 5 pounds 7 ounces
2500 grams / 5 pounds 8 ounces
2525 grams / 5 pounds 9 ounces
2550 grams / 5 pounds 10 ounces
2575 grams / 5 pounds 11 ounces
2600 grams / 5 pounds 12 ounces
2625 grams / 5 pounds 13 ounces
2650 grams / 5 pounds 13 ounces
2675 grams / 5 pounds 14 ounces
2700 grams / 5 pounds 15 ounces
2725 grams / 6 pounds
2750 grams / 6 pounds 1 ounces
2775 grams / 6 pounds 2 ounces
2800 grams / 6 pounds 3 ounces
2825 grams / 6 pounds 4 ounces
2850 grams / 6 pounds 5 ounces
2875 grams / 6 pounds 5 ounces
2900 grams / 6 pounds 6 ounces
2925 grams / 6 pounds 7 ounces
2950 grams / 6 pounds 8 ounces
2975 grams / 6 pounds 9 ounces
3000 grams / 6 pounds 10 ounces
3025 grams / 6 pounds 11 ounces
3050 grams / 6 pounds 12 ounces
3075 grams / 6 pounds 12 ounces
3100 grams / 6 pounds 13 ounces
3125 grams / 6 pounds 14 ounces
3150 grams / 6 pounds 15 ounces
3175 grams / 6 pounds 16 ounces
3200 grams / 7 pounds 1 ounces
3225 grams / 7 pounds 2 ounces
3250 grams / 7 pounds 3 ounces
3275 grams / 7 pounds 4 ounces
3300 grams / 7 pounds 4 ounces
3325 grams / 7 pounds 5 ounces
3350 grams / 7 pounds 6 ounces
3375 grams / 7 pounds 7 ounces
3400 grams / 7 pounds 8 ounces
3425 grams / 7 pounds 9 ounces
3450 grams / 7 pounds 10 ounces
3475 grams / 7 pounds 11 ounces
3500 grams / 7 pounds 11 ounces
3525 grams / 7 pounds 12 ounces
3550 grams / 7 pounds 13 ounces
3575 grams / 7 pounds 14 ounces
3600 grams / 7 pounds 15 ounces
3625 grams / 7 pounds 16 ounces
3650 grams / 8 pounds 1 ounces
3675 grams / 8 pounds 2 ounces
3700 grams / 8 pounds 3 ounces
3725 grams / 8 pounds 3 ounces
3750 grams / 8 pounds 4 ounces
3775 grams / 8 pounds 5 ounces
3800 grams / 8 pounds 6 ounces
3825 grams / 8 pounds 7 ounces
3850 grams / 8 pounds 8 ounces
3875 grams / 8 pounds 9 ounces
3900 grams / 8 pounds 10 ounces
3925 grams / 8 pounds 10 ounces
3950 grams / 8 pounds 11 ounces
3975 grams / 8 pounds 12 ounces
4000 grams / 8 pounds 13 ounces
4025 grams / 8 pounds 14 ounces
4050 grams / 8 pounds 15 ounces
4075 grams / 8 pounds 16 ounces
4100 grams / 9 pounds 1 ounces
4125 grams / 9 pounds 2 ounces
4150 grams / 9 pounds 2 ounces
4175 grams / 9 pounds 3 ounces
4200 grams / 9 pounds 4 ounces
4225 grams / 9 pounds 5 ounces
4250 grams / 9 pounds 6 ounces
4275 grams / 9 pounds 7 ounces
4300 grams / 9 pounds 8 ounces
4325 grams / 9 pounds 9 ounces
4350 grams / 9 pounds 9 ounces
4375 grams / 9 pounds 10 ounces
4400 grams / 9 pounds 11 ounces
4425 grams / 9 pounds 12 ounces
4450 grams / 9 pounds 13 ounces
4475 grams / 9 pounds 14 ounces
4500 grams / 9 pounds 15 ounces
4525 grams / 9 pounds 16 ounces
4550 grams / 10 pounds
4575 grams / 10 pounds 1 ounces
4600 grams / 10 pounds 2 ounces
4625 grams / 10 pounds 3 ounces
4650 grams / 10 pounds 4 ounces
4675 grams / 10 pounds 5 ounces
4700 grams / 10 pounds 6 ounces
4725 grams / 10 pounds 7 ounces
4750 grams / 10 pounds 8 ounces
4775 grams / 10 pounds 8 ounces
4800 grams / 10 pounds 9 ounces
4825 grams / 10 pounds 10 ounces
4850 grams / 10 pounds 11 ounces
4875 grams / 10 pounds 12 ounces
4900 grams / 10 pounds 13 ounces
4925 grams / 10 pounds 14 ounces
4950 grams / 10 pounds 15 ounces
4975 grams / 10 pounds 15 ounces
5000 grams / 11 pounds
Unknown/Unsure
g) Is your child:
Biological
Adopted
Fostered
Other
Prefer not to say
If other is selected please specify:
17. a) Has a psychologist ever assessed your child for specific learning difficulties?
Yes
No
b) If yes selected please specify (when):
c) If yes selected please specify (diagnosis):
18. Please rate your child on the following skills / milestones
Gross Motor Development
a) Rolled over (average 3.5 months):
Early
Normal
Late
Unsure
b) Sits without support (average 6.5 months):
Early
Normal
Late
Unsure
c) Walks unaided (average 12 months):
Early
Normal
Late
Unsure
d) Kicks a ball (average 18 months):
Early
Normal
Late
Unsure
e) Toilet trained (average 24 months):
Early
Normal
Late
Unsure
e) Rides tricycle (average 3 years):
Early
Normal
Late
Unsure
Fine Motor Development
a) Reaches/Grasps for object (average 4 months):
Early
Normal
Late
Unsure
b) Scribbles spontaneously (average 15 months):
Early
Normal
Late
Unsure
c) Stacks/piles blocks (average 18 months):
Early
Normal
Late
Unsure
d) Eats with a fork / spoon (average 24 months):
Early
Normal
Late
Unsure
Language Development
a) Smiles spontaneously (average 1 month):
Early
Normal
Late
Unsure
b) Says single words (average 12 months):
Early
Normal
Late
Unsure
c) Refers to self by first name (average 18 months):
Early
Normal
Late
Unsure
d) Knows full name (average 3 years):
Early
Normal
Late
Unsure
e) Names colours (average 3 years):
Early
Normal
Late
Unsure
19. Did your child have any developmental issue with “tummy time”?
Yes
No
a) Did they crawl on their belly (Commando crawl):
Please Select
Yes
No
At what age (month) did they start to crawl on their belly (Average 7 months):
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
b) Did they crawl on all fours?
Please Select
Yes
No
At what age (month) did they start to crawl (creep on all fours)(Average 8 months)
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
How long did they crawl (including commando and creeping)? )(Average 5 months)
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
c) At what age could they walk unsupported? (Average 13 months)
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
20. Has your child been experiencing headaches recently?
Yes
No
21. a) How frequent are the headaches?
Select
Daily
2-3 days a week
Weekly
Twice a month
Monthly
b) What days of the week do headaches generally occur?
Select
school days
weekends
any day
c) What time of day do headache occur?
Select
on waking
mornings
afternoon
evenings
late at night
d) How many headaches have occurred in the last 2 months?
e) Do you think there is a cause other than an eye problem that may be causing the headaches?
Select
Yes
No
(e.g. dehydration, neck problems, poor sleep patterns)
Please specify
*
22. a) How bad were the headaches?
Mildly distracting
Disturbing
Needing to take time off school
b) How many years have they been experiencing headaches like those they experience nowadays?
Please Select
Less than 3 months
Past 3 months
Past 6 months
Past 9 months
1 year
2 years
Greater than 2 years
c) What is the pain usually like?
Pulsating (throbbing)
Dull ache
Sharp / intense
Clamping
Other
If other is selected please specify:
d) What makes the headache worse?
Physical exercise (e.g. climbing stairs)
Reading
Noise
Bright light
Other
If other is selected please specify:
23. a) In general where is the pain located?
Top of head
Back of head
Forehead left side
Forehead right side
Forehead both sides
Around head
Temple Right side
Temple Left side
Temple Both Sides
In or around eyes
Behind eyes
b) How long does the pain usually last without medication?
Select
10-20 minutes
½ an hour
1 hour
2 hours
3-6 hours
½ a day
all day
c) How long does the pain usually last with medication?
Select
10-20 minutes
½ an hour
1 hour
2 hours
3-6 hours
½ a day
all day
d) Please name any medication that you administer to your child for headaches.
Panadol
Aspirin
Neurofen
Ibuprofen
Panadeine forte
Tylenol
Naproxen
Excedrin
e) Please select activities that you know can bring a headache on for your child:
Travelling in the car
Television
Reading
Sweets
School work
Cinema
Computers
Smells
Weekends
Exercise
Chocolate
Other
Please specify
24. Do they feel ill in any other way before or during headaches?
a) Loss of appetite?
Before
During
Not at all
b) Nausea?
Before
During
Not at all
c) Vomiting?
Before
During
Not at all
d) Numbness?
Before
During
Not at all
e) Tingling?
Before
During
Not at all
f) Feeling of weakness?
Before
During
Not at all
g) Difficulties with speech?
Before
During
Not at all
h) Dizziness?
Before
During
Not at all
i) Sensitivity to light?
Before
During
Not at all
j) Sensitivity to noise?
Before
During
Not at all
k) Visual Disturbances?
Before
During
Not at all
l) Other?
Before
During
Not at all
If other is selected please specify:
25. Appointment Booking
*
Select
I already have an appointment
I would like to make an appointment after submitting my form
Please contact me after reviewing my form
Please add any other comments below
Once submitted an email will also be forwarded to the email address you have supplied summarising all the details you have given. All details will also be forwarded to our optometrist.