General Information

First Name

Surname

Date of birth

Age

Male/Female/Other

Parent/guardian name(s)

Email

Contact Phone and/or Mobile Number

Address

Medicare number & child's reference number

Pre-school/Kindy/Daycare name and Teacher's/Carer's name

How did you hear about EyeSense Vision and Therapy Centre? *

GP details

Referred by:

Names of other tutors/therapists

Additional Information

1. Reasons for eye exam:

2. Any previous eye or vision concerns?

3 Any previous eye care? Please state when/with whom):

4. Brief health history, allergies and any current medications

5. Family History of General and/or Eye Disease, or vision problem or glassess

6. Have you noticed your child has a turned eye? if so, which eye turns in/out, and how often does it turn?

7. Any spectacles, eye surgery or patching?

8. Any serious injuries, concussion or surgery?

9. Was your child's pregnancy and birth normal? If no please give details?

10. Has your child's development required assistance eg speech therapy, OT, physiotherapy, educational psychology

11 Has your child's development and progress been as expected. Please provide details.

Is your child's body coordination? (please tick)

GoodAverageBelow average

Dominant hand ? (please tick)

RightLeftEither

Visual Function Indications.

Developmental Progress

Any diagnosis of developmental delay?Any gross motor delay or difficulty (crawling, body balance, walking)?Any fine motor delay or difficulty (eye-hand skills)?Any hearing/speech delay or difficulty?Any issues with anxiety or social interaction?Any issues with sleeping or eating/appetite?Any other areas of concern?

Does your child: (If yes, please tick)

Do you feel your child is not reaching their learning potential? If not please detail your concerns.

Advice

Costs will be approx. $140 -$190 for a 1 hour extensive appointment with a part Medicare rebate.
Medicare rebates can be submitted with your receipt.
Health fund rebates for spectacles and contact lenses can be claimed at the same time as you make payment in the office.
Our premises are located in the front office building on the ground floor to the right of the front door.
Parking is next door in the carpark to the left of the building with a gate code 3588# for entry.

Our allocated spaces are the 3rd and 4th on the right after entry. If these are occupied, there is usually paid parking in Newcastle St. Please DO NOT PARK in another space or you will be fined by City of Vincent.

If you have any documents you would like your optometrist to read, such as a doctor or teacher report, please email the documents to contact@eyesensevision.com.au.

If you or your child have any of the following symptoms, please do not come to the office, and contact us to reschedule your appointment.:

Sore throat or coughFeverTrouble breathingRunny nose

Thank you for choosing EyeSense Vision and Therapy Centre for your personal vision and eye health care. Please contact us if you have any questions, we look forward to meeting you!

Simoné Fanoy B Optom , Grad Cert Oc Ther, Ocular Medicines Prescriber

Liz Wason Dip App Sc (Optom), Grad Cert Oc Ther, FACBO, Ocular Medicines Prescriber