New patient sign-up - Child

Welcome to our practice

The development of your child's vision is affeted by certain illnesses, as well as the family history.  This questionnaire will provide information to complete a visual record, and aid us in determining how your child's vision has developed.

Title (Mastor/Miss)
First name *
Last name *
Address *
Suburb *
City *
Phone - Home *
Phone - Business
Date of birth
Medical Practitioner
Whom may we thank for recommending you to our practice?
Health History
Please check anything that applies below:
Is the child presently under physicians care?

Present situation

Does your child ever report:
Blurred vision
Eyes 'hurt' or 'tired'
Double vision
Have your ever noticed:
Excessive eye rubbing
Holding reading close
Frowning or squinting
Reversing words
Short attention span
Bumping into objects
Covers or closes one eye
Lerge pupils in bright light
General Health
Any alergies
Any significant injuries
or past illnesses
Currently on medications
Development History
Full term pregnancy?
Normal birth?
Is child active?
Family history
Are there any unusual eye conditions in the family?
Any diabetes in the family?
School history
Does child like to read?
Is the child's school work:
Better than expected?
As expected for ability?
Below what is expected?
Visual history
Child's eyes ever crossed?
Date of last visual exam
By whom
Name or person completing this form