New Child Info - [email protected]

optometry@cooroy
optometry@cooroy
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New Child Info

By filling out this form you will be giving us information to best assess your child's vision.
Your child's visual examination will be more than just a traditional eyesight test. As well as eyesight & eye health, we investigate how efficiently your child's eyes team together, how your child takes in information & how well they understand what they see. We believe optimal school performance required the development of optimal visual skills.
    • When attending the consultation please bring any spectacles your child has worn.
    • Bring any additional information or reports from other professionals that would help our understanding of yuour child.
    • In order to avoid distraction for your child, yourself and the optometrist during the examination, it would be appreciated if you could avoid bringing to the appointment siblings or other children who cannot be left alone in the waiting room or be quiet in the consulting room.
CHILDREN UNDER 5 YRS:  Expect this visit to last 30 to 45 minutes.   
Initial consultation direct-billed to Medicare unless your child has been billed a comprehensive consultation to Medicare within the past 36 months.*
PRIMARY SCHOOL (& YOUNGER HIGH SCHOOL) CHILDREN: Expect this visit to take up to 1 hour.   
Initial comprehensive consultation $105.00*
(up to $57.70 rebatable through Medicare).  

Our fees reflect the costs for providing more than just a basic vision test. We offer a comprehensive visual examination including a screening of important visual perceptual & processing skills that can impact on your child's learning.
OLDER SECONDARY SCHOOL CHILDREN: Expect this visit to take up to 45 minutes.
Initial comprehensive consultation $81.00* (up to $57.70 rebatable through Medicare)
We apply a 15% discount on most consultation items to Pension Concession Card holders.
*   Medicare will only provide the maximum ($57.70) rebate for a comprehensive consultation once every 36 mths for those under 65 years of age unless referred in writing by another optometrist or if the patient has a progressive eye disorder. A reduced rebate equal to that of a subsequent consultation however will still apply.
Questionnaire

MissMaster
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Residential Address

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Mailing address (if different to residential address)

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Phone & email contact



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Entitlements

NonePensionerHealth Care CardVeterans Affairs

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Visual history

YesNoNot sure
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YesNo

ConstantFor reading / near tasks onlyIn classFor distance

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 No Patching Tinted lenses or overlays
 Eye exercises / Vision therapy Eye surgery Other
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School & learning related questions




YesNo

 Reading? Spelling?
 Writing? Maths?
Possible signs of poor visual efficiency

 Headaches regularly Losing place when reading
 Head extremely tilted while doing close tasks Skipping words or lines when reading
 Short attention span when reading Words moving on the page
 Poor eye/hand coordination Fatigues quickly when reading
 Eye strain Poor reading comprehension
 Double vision Rubs eye when concentrating
 Excessive blinking Holds books / devices very close
 Excessive rubbing eyes One eye turning in
 Blurred vision when reading One eye turning out
 Blurred vision for distance Squinting
 Glare sensitivity Covering one eye
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Possible signs of visual processing difficulties

 Reversing letters and numbers Difficulties with sight words
 Not recognising the same word repeated on a page Disorganised handwriting
 Poor reading comprehension Mistakes words with similar beginnings
 Slow learning to read Can respond orally but not in writing
 Trouble with spelling Slow copying from board to book
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Learning / Developmental History



YesNoNot sure

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62 Maple Street
Cooroy Qld 4563
Ph:   07 5442 5555
optometry@cooroy
Ph:   07 5442 5555
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