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Home
About Us
Our Services
Adults
Eye Examinations & Eye Health
Behavioural Optometry
Contact Lenses & Ortho-K
Children
Vision Therapy
Children’s Vision
Eyewear
Frames
Lenses
Sunglasses
Contact Lenses & Ortho-K
Contact Us
Book Now
Questionnaires
Child Questionnaire
Adults Questionnaire
Questionnaires
Adult Questionnaire
Help us understand what brought you to our practice, and how we can assist best.
Personal Details
Name
(Required)
First
Middle
Last
Preferred Name
Date of Birth
(Required)
Home Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
(Required)
Mobile Phone
(Required)
Home Phone
What has prompted your visit? Have you been referred in, and if so, by whom and why?
(Required)
Complete Medicare Number
(Required)
Medicare Card Position
(Required)
Medicare Expiry Date
(Required)
Do you have a private health fund?
(Required)
Yes
No
Private Health Fund Name
(Required)
Occupation
Sport/Hobbies/Crafts
Visual History
Are you experiencing any eye or vision problems at this point in time?
When and where was your last eye exam?
Have you ever worn glasses? Please Detail
Have you ever worn contact lenses? Please Detail
Have you had eye surgery? Please Detail
Have you ever had vision therapy/eye exercises? Please Detail
Have you ever had an eye injury? Please Detail
Do you have vision problems with sport/hobbies?
Does your job include using a computer terminal?
(Required)
Yes
No
How many hours per day?
(Required)
How many screens do you use and how far away from you are they?
(Required)
Do you experience any of the following (please select at least one answer in each row)
(Required)
Yes
No
Headaches
Eyes Hurt/Tired
Frequently Red
Closing/Covering one eye
Blurred Vision Far
Double Vision
Blurred Vision Near
Eye turns in or wander out
Health History
How is your general health?
(Required)
Excellent
Good
Fair
Poor
Please check any of these conditions that apply to you or run in your family (please select at least one answer in each row):
(Required)
Yes
No
Relative
Dry Eye
Lazy/Turned Eye
Cataracts
Macular Degeneration
High Blood Pressure
Diabetes
Arthritis
Asthma
Migraine/Headache
Heart Disease
Have you had any of the following:
(Required)
Head Injury
Concussion
None
Please describe the event, treatment and any ongoing effects .
(Required)
Indicate any allergies
Indicate any current medications
Name of your GP
First
Last
Address of your GP
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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