Child Questionnaire | Susan Walton Optometrist

Child's Details

Child’s name*

Preferred name

Date of birth*

Complete Medicare no.*

Medicare Card Position

Medicare Expiry Date*

Private Health Fund

Home Address*

Suburb*

Postcode*

Best Contact Email Address*

Home telephone number

Mobile number

School attended

Grade/Year

Teacher’s name

Doctor’s name

Doctor’s address

Parent/Carer Details

Parent/Carer 1’s Full Name*

Parent/Carer 1’s phone number*

Parent/Carer 1's Home telephone number

Parent/Carer 2’s Full Name

Does the child live with both parents?*

Yes
No

If no, how much time with each?

From whom did you hear of our services?

Child's present area of difficulty

Reading
Writing
Spelling
No definite preferred hand
Co-ordination
Speech
Behaviour
Delayed Development
Concentration

Any other problems?

Family History

Family and/or relative with reading problems
Ambidextrous
Left Handed
Poor co-ordination
Similar problem to child

Brothers and Sisters

Name

Age

Position in Family

Handedness

Name

Age

Position in Family

Handedness

Name

Age

Position in Family

Handedness

Birth History

Did Mother have any of the following during pregnancy?

Infectious Disease
Severe Trauma
High blood pressure
Toxaemia
Medication
Oedema
Haemorrhage
Pregnancy difficult to maintain

Was Labour?

Normal
Induced
Assisted
Caesarean
Instruments used

Was Labour?

None
General
Local
Spinal

Type of Presentation

Head
Breech
Feet

Did Mother smoke during pregnancy?

Yes
No

Length of Labour (hrs)

Birth Weight

Gestation (weeks)

Describe any birth complications

Motor Skills

	Yes	No
Do you consider your child has poor motor co-ordination?
Was your child unable to learn to run, hop, jump, skip easily?
Was your child late to develop a preferred hand (after 2 ½)?
Are they poor at ball games (catching/hitting) or at sports?
Do you consider they have poor balance?

Post Natal History

	Yes	No
Was baby well at birth?
Did baby have difficulty crying or breathing after birth?
Did baby have difficulty sucking in first 24hrs?
Was baby bottle fed?
Was baby breast fed?
Was disposition of baby abnormal?
Was feeding difficult to establish?
Did baby fail to regain birth weight by 5 days?
Did baby have jaundice?
Did baby have any sleeping difficulties in the first 6 months?
Did the baby have any feeding difficulties in the first 6 months?

Developmental History

	Yes	No
Did baby object to lying on their front?
Did they seem active to you?
Did they seem to inactive/lack curiosity to you?
Was child slow learning to roll over?
Did child omit stage of moving on floor on their tummy?
Was child propped to learn to sit?
Were they able to sit alone at 8 months?
Did they shuffle around on their bottom?
Did they not crawl on hands and knees?
Did they walk before 10 months?
Did they walk after 18 months?
Was walking clumsy for a long time?
Did they spend more than 1-2hrs daily in a playpen?
Did they spend more than 1-2hrs daily in a walker?

Personality

Hearing and Speech

	Yes	No
Are you concerned about their hearing?
Are they sensitive/upset by loud noises?
Was development of speech considered abnormal?
Do they have difficulty expressing themselves fluently?
Has your child had a hearing test?

If yes, was the hearing test normal?

General Development

	Yes	No
As an infant did they object to being cuddled?
Do they appear to have a high pain tolerance?
Do they appear to have a very low pain tolerance?
As an infant were they upset by movement/play?
As an infant do they lack a sense of adventure?
Was their sense of danger poorly developed by age 2?
Were they a climber extraordinaire?
Do they continue to have minor accidents (falls, bumps)?
Did they have difficulty learning left from right by age 6?
Do they get car sick?
Do they touch everything especially when in new places?
Are they always asking questions?

Medical History

Please check any conditions your child has suffered

Others?

Is your child on any medication?

Yes
No

If yes, please detail

Allergies

Persistently blocked nose
Snuffly baby
Hay fever
Asthma
Sinusitis
Eczema

Known food allergies

Yes
No

Other Allergies

Abnormal reactions to immunisations

Yes
No

Any of the following?

Convulsions
Epilepsy
Chronic diarrhoea
Constipation
Poor appetite
Lack of energy
Excessive Sweating
Obesity

Injury

Head injury
Concussion
Broken Bones
Poisoning

Other?

Disorders of

Blood
Kidneys
Heart
Lungs
Gastrointestinal tract

Nutrition & Diet

What beverages do they like to drink?

What vegetables and fruit do they like to eat?

What vegetables and fruit do they dislike?

List the foods they like the most

List the foods they dislike most

Schooling

Does your child like going to school?

Yes
No

Does your child have a behaviour problem at school?

If yes, please describe

Has your child had any of the following?

Special remedial help (eg. Reading Recovery)
Psychological testing

Has your child repeated a grade?

Yes
No

How does your child get along with other classmates?

Liked
Class clown
A loner
A leader
A bully

In what state does your child seem at the end of the school day?

Tired
Irritable
Emotional

Is this the same on weekends and/or holidays?

How easy is it to get your child to engage in homework or reading/ writing tasks?

Please list any specialists/consultants seen Eg. vision, auditory, occupational therapist, speech pathologist

Date

Institution/consultant

Specialty

Results

Date

Institution/consultant

Specialty

Results

Date

Institution/consultant

Specialty

Results

Visual History

Does one eye turn in our out?

Yes
No

When did you first notice this?

Have they had any previous eye exams?

Yes
No

When?

Were glasses prescribed?

Has patching of one eye been prescribed?

Yes
No

If yes, how long was the patch worn for?

Does child dislike bright light, especially when outside?

Yes
No

Does child screw up one eye when in bright light?

Yes
No

Outdoor Activities

Does your child spend time outside?

How much?

Describe the activities they like to do outside

Electronic Devices

Does your child use devices?

How much time daily?

Are there any house rules in place?

Does time on devices seem to affect your child’s mood?

Questionnaire for Children and Students new to our clinic

Child's Details

Parent/Carer Details

Child's present area of difficulty

Family History

Brothers and Sisters

Birth History

Motor Skills

Post Natal History

Developmental History

Personality

Hearing and Speech

General Development

Medical History

Allergies

Any of the following?

Injury

Disorders of

Nutrition & Diet

Schooling

Please list any specialists/consultants seen Eg. vision, auditory, occupational therapist, speech pathologist

Visual History

Outdoor Activities

Electronic Devices

Get In Touch!

New to our Practice

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Get In Touch!

New to our Practice

Opening Hours

Newsletter