New Patient Information Form - Vision Advantage

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New Patient Form

Home
Behavioural Optometry
Vision Therapy
Children’s Vision
Eyecare
Eyewear
Articles
More About Us
Contact Us
New Patient Form

Book Online Now

Behavioural Optometry
Vision Therapy
Children’s Vision
Eyecare
Eyewear
Articles

Behavioural Optometry
Vision Therapy
Children’s Vision
Eyecare
Eyewear
Articles

New Patient Information Form

Thank you for coming to our office! How did you hear about us?
Patient’s name
Date of Birth
Address
Your email
Parent/ Guardian Name(s)
Relationship to Patient
Patient’s occupation/ school
Grade
Hobbies
Names and ages of immediate family
You give permission for us to contact Medicare to check your eligibility code for the service we will be providing today.
- Yes
- No
OCULAR HISTORY
Are you interested in any of the following?
- Glasses
- Contacts
- LASIK
- Vision Therapy
Last eye exam
Previous optometrist
Do you have glasses?
- Yes
- No
When are they used?
- Distance
- Near
Do you have contacts?
- Yes
- No
What brand (if known)?
What is the main reason for your visit today?
Do you currently have any vision-related issues?
- Blurred vision
- Loss of vision
- Floaters in vision
- Eye turn
- Halos in vision
- Head tilt/ face turn
- Motion sickness/ carsickness
- Discomfort with 3-D movies
- Poor reading comprehension
- Poor tracking/ eye movements
- Double vision
- Flashes in vision
- Blind spots
- Lazy eye
- Light sensitivity
- Lose attention easily
- Other
Other Vision Related Issues
Do you currently have any eye comfort-related issues?
- Dry eyes
- Tired eyes
- Watery eyes
- Gritty/sandy feeling
- Burning eyes
- Eye pain
- Red eyes
- Eye soreness
- Itchy eyes
- Gritty/sandy feeling
- Other
Other eye comfort related issues
Do you currently have any motor-related issues?
- Poor motor control
- Trouble catching a ball
- clumsy/stumble easily
- Other
Other motor-related issues
Do you currently have any eye disease?
- Cataracts
- Glaucoma
- Styes
- Keratoconus
- Macular degeneration
- Other
Other eye disease
Describe any eye injuries
List any eye surgeries
List any eye drops used
PLEASE TELL US IF YOU HAVE EVER...
Sustained a head injury or trauma?
- Yes
- No
Been diagnosed with Autism or Spectrum Disorder?
- Yes
- No
Been diagnosed with Attention Deficit Disorder (ADD)/ Attention Deficit Hyperactivity Disorder (ADHD):
- Yes
- No
ADDITONAL MEDICAL INFORMATION
Doctor Name
Clinic
Last visit
List any current or previous medical problems
List all prescription medications and any vitamins/supplements/over-the-counter medications you are taking (please include dosage and frequency)
List any medication you are allergic to
Are you pregnant or nursing?
- Yes
- No
When is it due/birth date?
FAMILY MEDICAL HISTORY
Do your family members (grandparents, parents, siblings) have any of the following?
Blindness
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Glaucoma
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Cataracts
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Macular Degeneration
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Eye Turn (Strabismus)
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Lazy eye (Amblyopia)
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Retinal Detachment
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Rheumatoid Arthritis
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Cancer
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Diabetes
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
High blood pressure
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Stroke
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Heart disease
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
DEVELOPMENTAL HISTORY
Is the Patient under 18 years old?
- Yes
- No
Length of pregnancy
Type of delivery
- Natural
- C-section
- Forceps/ vacuum
- Anaesthesia
Child’s birth weight
Child is
- Biological
- Adopted
- Foster
- Other
During the pregnancy of this child, did any of the following occur?
- Toxemia
- Trauma
- Injury by fall
- Severe illness
- Prescribed medication
- Tobacco use
- Alcohol use
- Drug use
Please explain
How is your child performing to others his/her age?
- Above average
- Average
- Below average
Are there any specific concerns with learning?
How well is your child’s spoken vocabulary?
- Above average
- Average
- Below average
Has your child undergone any of the following testing/treatment/ therapy?
Educational
- Yes
- No
Neurological
- Yes
- No
Psychological
- Yes
- No
Occupational
- Yes
- No
Speech/ auditory
- Yes
- No
Physical
- Yes
- No
Describe
Does your child eat well?
Thank you. Please select "Submit" to complete the form.

New Patient Information Form

Thank you for coming to our office! How did you hear about us?
Patient’s name
Date of Birth
Address
Your email
Parent/ Guardian Name(s)
Relationship to Patient
Patient’s occupation/ school
Grade
Hobbies
Names and ages of immediate family
You give permission for us to contact Medicare to check your eligibility code for the service we will be providing today.
- Yes
- No
OCULAR HISTORY
Are you interested in any of the following?
- Glasses
- Contacts
- LASIK
- Vision Therapy
Last eye exam
Previous optometrist
Do you have glasses?
- Yes
- No
When are they used?
- Distance
- Near
Do you have contacts?
- Yes
- No
What brand (if known)?
What is the main reason for your visit today?
Do you currently have any vision-related issues?
- Blurred vision
- Loss of vision
- Floaters in vision
- Eye turn
- Halos in vision
- Head tilt/ face turn
- Motion sickness/ carsickness
- Discomfort with 3-D movies
- Poor reading comprehension
- Poor tracking/ eye movements
- Double vision
- Flashes in vision
- Blind spots
- Lazy eye
- Light sensitivity
- Lose attention easily
- Other
Other Vision Related Issues
Do you currently have any eye comfort-related issues?
- Dry eyes
- Tired eyes
- Watery eyes
- Gritty/sandy feeling
- Burning eyes
- Eye pain
- Red eyes
- Eye soreness
- Itchy eyes
- Gritty/sandy feeling
- Other
Other eye comfort related issues
Do you currently have any motor-related issues?
- Poor motor control
- Trouble catching a ball
- clumsy/stumble easily
- Other
Other motor-related issues
Do you currently have any eye disease?
- Cataracts
- Glaucoma
- Styes
- Keratoconus
- Macular degeneration
- Other
Other eye disease
Describe any eye injuries
List any eye surgeries
List any eye drops used
PLEASE TELL US IF YOU HAVE EVER...
Sustained a head injury or trauma?
- Yes
- No
Been diagnosed with Autism or Spectrum Disorder?
- Yes
- No
Been diagnosed with Attention Deficit Disorder (ADD)/ Attention Deficit Hyperactivity Disorder (ADHD):
- Yes
- No
ADDITONAL MEDICAL INFORMATION
Doctor Name
Clinic
Last visit
List any current or previous medical problems
List all prescription medications and any vitamins/supplements/over-the-counter medications you are taking (please include dosage and frequency)
List any medication you are allergic to
Are you pregnant or nursing?
- Yes
- No
When is it due/birth date?
FAMILY MEDICAL HISTORY
Do your family members (grandparents, parents, siblings) have any of the following?
Blindness
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Glaucoma
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Cataracts
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Macular Degeneration
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Eye Turn (Strabismus)
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Lazy eye (Amblyopia)
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Retinal Detachment
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Rheumatoid Arthritis
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Cancer
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Diabetes
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
High blood pressure
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Stroke
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
Heart disease
- Yes
- No
Who?
- Mother
- Father
- Sibling
- Grandparent
DEVELOPMENTAL HISTORY
Is the Patient under 18 years old?
- Yes
- No
Length of pregnancy
Type of delivery
- Natural
- C-section
- Forceps/ vacuum
- Anaesthesia
Child’s birth weight
Child is
- Biological
- Adopted
- Foster
- Other
During the pregnancy of this child, did any of the following occur?
- Toxemia
- Trauma
- Injury by fall
- Severe illness
- Prescribed medication
- Tobacco use
- Alcohol use
- Drug use
Please explain
How is your child performing to others his/her age?
- Above average
- Average
- Below average
Are there any specific concerns with learning?
How well is your child’s spoken vocabulary?
- Above average
- Average
- Below average
Has your child undergone any of the following testing/treatment/ therapy?
Educational
- Yes
- No
Neurological
- Yes
- No
Psychological
- Yes
- No
Occupational
- Yes
- No
Speech/ auditory
- Yes
- No
Physical
- Yes
- No
Describe
Does your child eat well?
Thank you. Please select "Submit" to complete the form.

Got a question?

Give us a call on 03 9398 1344

or send a quick message using this form:

Name

Phone

Email

Message

Make an Appointment

Give us a call on 03 9398 1344

or use our online Booking Portal:

Book Online Now

Location

Eyecare Plus Altona / Vision Advantage

90 Railway St S, Altona VIC 3018

Hours

Mon – Fri: 9am – 5.30pm

Thursday night available by appointment

Saturday: 9am – 2pm

Vision Advantage has special qualifications and training to undertake a series of Behavioural Optometry tests to assess a childs visual performance and function then implement Vision Therapy to improve and correct these weaknesses.

Behavioural Optometry is a holistic combination of eyesight, eye coordination and positioning, and how the brain interprets, processes and acts on the information.

Vision Therapy is a customised and personalised program of eye and brain exercises designed to teach and strengthen a wide range of vital children’s (and adults) visual skills.

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