New Patient Information Thank you for booking with us. Before your appointment please take the time to fill in this form so we know how to best help you. TitleMrMrsMissMasterOther First Name * Surname * Known As(if different from above) Date Of Birth * Address * Suburb * Phone Number * Email * What is the main reason for your visit today? If completing this form for a dependant please provide Parent/Guardian Name and Date of Birth. (required for medicare claims) Parent/Guardian Name Parent/Guardian date of birth (for Medicare claims) Additional Information GP Name GP Clinic/Suburb Current Medications Private health insurance? If yes, which provider? Occupation Sports/hobbies Medical HistoryYou/Relative (select all that apply) Short sightedness You Relative Long sightedness You Relative Lazy eye or squint You Relative Colour vision problem You Relative Eye diseases You Relative Eye injury You Relative Eye surgery You Relative Blindness You Relative Cataracts You Relative Glaucoma You Relative Macular degeneration You Relative Diabetes You Relative High blood pressure You Heart Problems You Allergies/asthma/skin problems You Cancer You Arthritis You Nerve problems You Autism spectrum disorder You Head injury (including concussion) You Other Vision RequirementsHave/Interested In (select all that apply) Glasses Have Interested In Contact lenses Have Interested In A spare pair of glasses Have Interested In Sunglasses Have Interested In Prescription sunglasses Have Interested In Sleep Contacts/Ortho K Have Interested In Do you experience... (select all that apply) Burning/itchy/gritty/watery/dry eyes Yes Sore eyes Yes Red eyes Yes Eyestrain Yes Floating spots/flashing lights in vision Yes Headaches Yes Reading difficulties Yes Double vision Yes Uncomfortable glasses Yes Sudden loss of vision Yes Sensitivity to light Yes Issues with glare Yes Blurry vision up close/far away Yes Motion sickness Yes How did you hear about us?Please Select...Friend/RelativeInternet SearchDoctorOther Name of referrer Please complete if your child is under 16 years of age Signs of poor visual efficiency Does your child show signs of/complain of: Yes Eyestrain Yes Double vision Yes Headaches Yes Excessive blinking Yes Blurred vision when reading Yes Glare sensitivity Yes Loses place when reading/skips words and lines often Yes Words moving on the page Yes Short attention span/becomes fatigued when reading Yes Poor reading comprehension Yes Rubs eyes when concentrating Yes Holds books/devices very close Signs of visual processing difficulties Does your child show signs of/complain of: Yes Reversing letters and numbers Yes Not recognising the same word repeated on a page Yes Poor reading comprehension Yes Slow learning to read Yes Trouble with spelling and sight word vocabulary Yes Untidy writing Yes Mistakes words with similar beginnings Yes Can respond orally but not in writing Yes Slow copying from board to book Name of school Year level Teacher's name Has your child's school progress been as expected for their ability?YesNo- Does your child have difficulty withReadingWritingSpellingMaths Additional HistoryYes/No (select all that apply) Has there been any remedial teaching? YesNo- Is there a history of learning problems in the family? YesNo- Does your child have a history of delayed developmental milestones? (eg. speech/gross motor skills) YesNo- Has your child repeated a grade? YesNo- Has your child had an auditory assessment? YesNo- Has your child had a speech pathology assessment/therapy? YesNo- Has your child had an occupational therapist assessment/therapy? YesNo- Has your child seen a paediatrician? YesNo- Notes I acknowledge that I have read and agreed to the privacy statement below * Yes Send PRIVACY STATEMENT: Our practice respects your privacy & will comply with the Privacy Act & Australian Privacy Principles when handling your personal information. The information provided on this form helps us to make informed decisions on how to best meet your eyecare and eyewear needs. We may use your personal contact information to send you information regarding eye health, eyecare and eyewear, with your consent. We may also need to provide some personal information to third party suppliers (such as mail-out and electronic distribution services & eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy.
