Strathpine
345 Gympie Road
Strathpine
(07) 3205 1593

Caboolture
Shop 27a Caboolture Square Shopping Centre
60-78 King Street
Caboolture
(07) 5495 2316

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    Parent Pre Examination Questionnaire

    This form provides initial information for a Visual Examination. This examination goes beyond the traditional sight examination. It investigates how efficiently your child understands what he/she sees. Optimum school performance requires optimum visual function.


    Your Details

    YesNo
    YesNoUnsure

    Visual History

    YesNo
    YesNo

    Has your child seen any of the following Allied Health Practitioners?
    Occupational TherapistSpeech TherapistChiropractorPaediatrician


    Family Visual History




    YesNo
    YesNo

    YesNo

    Signs and Symptoms

    Please select the option that most applies to the following symptoms.


    School History

    YesNo
    YesNo

    Developmental/Health History

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    Written Report

    A written report is available. The cost is $30.00 (for up to 3 copies).

    YesNo