New Child Info Online - [email protected]

optometry@cooroy
optometry@cooroy
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New Child Info Online

You may prefer to print a pdf version of the questionaire to bring with you on the day or email to us ahead of time.

By filling out the online questionnaire below 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.

Billing Information

CHILDREN UNDER 5 YRS:  
Expect this visit to last 30 to 45 minutes.   
Initial consultation direct-billed to Medicare only if your child has not been billed a comprehensive consultation by an optometrist with Medicare within the past 36 months.*
PRIMARY SCHOOL (& YOUNGER HIGH SCHOOL) CHILDREN:
Expect this visit to take up to 1 hour.   
Initial comprehensive behavioural consultation $130.00*
(up to $58.55 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. Retinal imaging might be included.
OLDER SECONDARY SCHOOL CHILDREN:
Expect this visit to take around 45 minutes.
Initial comprehensive consultation $89.00*   
(up to $58.55 rebatable through Medicare)'
EXTRA TESTING: Additional costs will be incurred if the optometrist recommends extra tests such as retinal imaging or scans.
We apply a 15% discount on most consultation items to Pension Concession Card holders.  (Fees are subject to change).
ABOUT MEDICARE REBATES

*   Medicare will only provide the maximum ($58.55) 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.

If under 36 months a reduced rebate equal to that of a subsequent consultation ($29.35) however will still apply.
Questionnaire

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MissMasterNone
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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 / INSURANCE

None
Pensioner
Health Care Card
Veterans Affairs

YesNoNot sure
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VISUAL HISTORY


YesNoNot sure
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YesNo

All or most of the timeIn class
For reading / near For distance

YesNo

 No Eye surgery
 Eye exercises Tinted lenses
 Vision Therapy Overlays
 Patching Other
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 Strabismus (eye turn) Glaucoma
 Amblyopia (lazy eye) Macular Degeneration
 Learning problems or dyslexia Retinal Detachment
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SCHOOL & LEARNING RELATED QUESTIONS




YesNo

YesNo

 Reading? Spelling?
 Writing? Maths?

YesNo
SIGNS OF POSSIBLE POOR VISUAL EFFICIENCY

 Blurred vision for distance Losing place when reading
 Blurred vision when reading Poor reading comprehension
 Squinting Fatigues quickly when reading
 Double vision Skipping words or lines when reading
 Headaches regularly Eye strain
 One eye turning in Excessive blinking
 One eye turning out Excessive rubbing eyes
 Covering one eye Rubs eye when concentrating
 Head extremely tilted while doing close tasks Glare sensitivity
 Holds books / devices very close Poor eye/hand coordination
 Short attention span when reading
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SIGNS OF POSSIBLE VISUAL PROCESSIONG DIFFICULTIES

 Reversing letters and numbers Disorganised handwriting
 Not recognising the same word repeated on a page Mistakes words with similar beginnings
 Poor reading comprehension Can respond orally but not in writing
 Slow learning to read Slow copying from board to book
 Trouble with spelling Words moving on the page
 Difficulties with sight words Trouble with black print on a white page
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MEDICAL / DEVELOPMENTAL HISTORY





YesNoNot sure

 Educational psychologist Occupational therapist
 Speech pathologist Paediatrician
 Audiologist

YesNo

YesNo

REFERRAL

 Friend or relative Facebook
 Teacher Local / signage / advertising
 Tutor Newspaper adverstisement
 Medical professional Newspaper editorial
 Other optometrist  Yellow Pages
 Other professional Local Phone Book
 Internet search Other
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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). Please contact us if you would like to know more about how we handle personal information.
62 Maple Street
Cooroy Qld 4563
Ph:   07 5442 5555
optometry@cooroy
Ph:   07 5442 5555
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