Patient Information Form

Thank you for choosing to fill in the Pre-Examination Questionnaire.

Thank you for choosing to fill in the pre examination form. This will help us make sure that your optometrist will be informed of your vision requirements for your visit. Note: You can select multiple values by holding down the CTRL key (PC) or Command key (MAC)
Eye Health
Aboriginal and/or Torres Strait Islander Origin
Are you of Aboriginal or Torres Strait Islander origin? (for persons of both Aboriginal and Torres Strait Islander origin select both 'Yes' options)
General Health
Do you suffer from
General Health - Other
General Practitioner
Please provide your usual doctor’s name, address and telephone number
Personal Eye Health
Do you suffer from
Personal Eye Health - Other
Family Eye Health
Please choose the corresponding field if this matches a condition that occurred in your parents/siblings
Family Eye Health - Other
Medication
Please list all the medications and/or herbal supplements you're currently taking

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