Online Forms

Due to COVID-19 our office is open by appointment only. When you arrive at the office please stay in your vehicle and call 306-585-2424 to check-in. We will review your information over the phone and will let you know when we are ready to welcome you into the office. If you have a mask we would appreciate you wearing it, however it is not mandatory. Thanks for your cooperation!

Home Forms Child Patient History

Child Patient History

Patient First & Last Name

Date of Birth

Sask Health Card #

Parent/Guardian Name(s):

Parent Email Address

Parent Phone Number

Name of School

Grade

The following information will help Drs. Machmer and McAvoy in the assessment and diagnosis of your child's visual development and processing. Please answer to the best of your knowledge.

Do you have any concerns with their vision or motor skills? If so, please describe:

Please check any of the following conditions that they have been diagnosed with:

Other Conditions:

Please list any current medications:

Birth, Infancy, and Toddler Years

Were they born?	Prematurely	Full-term	Unknown
How were they delivered?	Vaginally	C-section	Unknown
Were forceps used during delivery?	Yes	No	Unknown
Any complications during pregnancy?	Yes	No	Unknown
Any complications during birth?	Yes	No	Unknown
Was an incubator or oxygen used?	Yes	No	Unknown

When were the following milestones met:

Crawling	Early	Average	Delayed	N/A
Walking	Early	Average	Delayed	N/A
Speaking	Early	Average	Delayed	N/A
Potty Trained	Early	Average	Delayed	N/A

Motor Skills:

Can they do the following:

Stand/Hop on one foot	Yes	No
Catch a ball	Yes	No
Ride a bike	Yes	No
Have difficulty with balance	Yes	No
Struggle with hand-eye co-ordination	Yes	No
Right or left handed	Right	Left

School Aged (if applicable):

Do they:

Enjoy School	Yes	No	Sometimes
Enjoy reading	Yes	No	Sometimes
Enjoy being read to	Yes	No	Sometimes
Read at or above grade level	Yes	No	Sometimes
Comprehend what they read	Yes	No	Sometimes
Reach their potential in school	Yes	No	Sometimes
Print neatly	Yes	No	Sometimes
Reverse letters	Yes	No	Sometimes
Come home from school exhausted	Yes	No	Sometimes
Come home from school with headaches	Yes	No	Sometimes
Have any classroom adaptations	Yes	No	Sometimes

Do you and/or their teacher have any concerns with their school performance and/or behaviour?
If so, please describe: