Questionnaire for Adults New to Our Clinic

We ask you to take a few moments to complete this form. The purpose of collecting this information is to assist us in providing you with the highest quality eye-care. All information will be treated in the strictest confidence in accordance with the Privacy Act. As you complete this history questionnaire we hope that you will recognize the thoroughness with which your vision will be considered.

  • DD slash MM slash YYYY
  • Visual History

  • Do you experience any of the following?

  • YesNo
    Visual Headaches
    Eyes hurt/tired/frequently red
    Closing/covering one eye?
    Blurred Vision Far
    Double Vision
    Blurred at Near
    Eye turns in or wander out?
  • Please check any of these eye conditions that apply to you or run in your family

  • YesNoRelative
    Dry Eye
    Lazy Eye/Turned Eye
    Macular Degeneration
    Eye surgery
    Floaters/Spots in Vision
    Flashing Lights
    Retinal Detachment
    Colour blindness
    Glare Sensitive
  • Health History

  • Please check any of these health conditions that apply to you or run in your family

  • YesNoRelative
    High Blood Pressure
    Elevated Cholesterol
    Depression/Mental Illness
    Heart disease
    Thyroid disease
    Skin disease
    Head injury
    Drug sensitive/allergies
    Weight loss/gain
    Multiple Sclerosis
  • This field is for validation purposes and should be left unchanged.