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Patient Information Form
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Patient Information Form
Patient Information Form
Jon Harsem
2019-11-21T12:25:34+10:00
Pre Exam Questionnaire
Thank you for choosing to fill in the Pre-Examination Questionnaire.
Step
1
of
2
50%
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
No
Yes, Aboriginal
Yes, Torres Strait Islander
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
High Blood Pressure
Diabetes
Heart Disease
Other
General Health - Other
General Practitioner
Please provide your usual doctor’s name, address and telephone number
Personal Eye Health
Do you suffer from
Irritated/Sore Eyes
Trouble with focussing
New Headaches
Blurred Vision
Red Eyes
Watery Eyes
Dry Eyes
Tired Eyes
Daytime Glare
Nighttime Glare
Double Vision (image split in two)
Cataract
Glaucoma
Macular Degeneration
Previous Surgery/Other
Personal Eye Health - Other
Family Eye Health
Please choose the corresponding field if this matches a condition that occurred in your parents/siblings
Cataract
Glaucoma
Macular Degeneration
Previous Surgery/Other
Family Eye Health - Other
Medication
Please list all the medications and/or herbal supplements you're currently taking
Lifestyle
Do you currently wear glasses and/or contact lenses?
Glasses
Contact Lenses
Neither
Vision Correction
For what vision correction do you wear your glasses/contact lenses (select all that apply)?
Distance (far away)
Intermediary (0.6-1m)
Near (0.4-0.6m)
Are you happy with your current glasses or contact lenses?
Yes
No
In which area would you like us to assist with your vision?
Day/Night Driving
Car Dashboard
Computer
Reading
Other
Other vision assistance
Email
This field is for validation purposes and should be left unchanged.
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