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    Prep/Primary Teacher Pre-Examination Questionnaire

    We have been asked to do a visual assessment on this child. As visual development and general development are inter-related, it would be helpful to our assessment if you could fill in the following questionnaire on your observations.


    Authorisation

    I grant permission for the release of confidential information regarding the below child to RA Optometrists.


    Kindy/Pre-School Information


    Child’s Information (Confidential)

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    Please grade the child's skill level in the following tasks:

    Competent  Minor Difficulty  Poorly Developed
    Competent  Minor Difficulty  Poorly Developed
    Competent  Minor Difficulty  Poorly Developed
    Competent  Minor Difficulty  Poorly Developed
    Competent  Minor Difficulty  Poorly Developed
    Competent  Minor Difficulty  Poorly Developed
    Competent  Minor Difficulty  Poorly Developed

    Have you observed any of the following? Please select.

    GENERAL BEHAVIOUR
    Complains of headaches
    Dislikes tasks requiring sustained visual concentration
    Irritability or restlessness after close work
    Frequent sties
    Blinks excessively
    BODY POSTURE AND SPACE AWARENESS
    Covers or closes one eye
    Unusual awkwardness
    Frequent tripping or stumbling
    Improper or awkward posture while colouring or reading
    Avoids close work
    Complains of double vision
    Tilts head to one side
    Rubs eyes frequently

    APPEARANCE OF EYES
    Eyes turn in
    Eyes turn out
    Watering eyes
    Bloodshot eyes
    Red rimmed, crusted or swollen lids
    Daydreaming or inattentiveness
    Frowns, scowl or squints

    Further information

    Do you have any further comments on this child's abilities?