How did you find out about our practice?

Medicare Reference No. *

Medicare Expiry Date *

Do you have private health insurance for optical extras? *

Yes

Private Health Fund Provider

What Is Your Doctor's Name?

What are the main reasons for your visit to our practice?

When was your last eye examination?

Where was your last eye examination?

Did the last eye care practitioner diagnose and/or treat any conditions on your last visit?

Yes

If yes then, what was diagnosed and what treatment was recommended?

It is important for us to understand how you live your life in order to provide you with a tailored eyewear solution to suit your needs and lifestyle. Please answer the questions below to give us an insight into yours.

Do you currently wear glasses? *

Yes

What do you wear your glasses for?

How old is your current pair?

Do you have more than 1 pair of glasses?

Yes

If yes, what do you wear your other pair of glasses for?

Do your glasses feel heavy on your face at the end of the day?

Yes

Outdoors And Protection *

I spend lots of time outdoors.

I have a problem with glare.

I wear prescription sunglasses

I require safety glasses for my work or hobbies

I wear non prescription sunglasses

Computers and Screen Devices *

My work requires computer use.

I have a dedicated pair of computer/office spectacles.

I spend less than 2 hours on the screen.

I spend more than 2 hours in the screen.

I experience eye fatigue after extended computer use.

Hobbies, Sports and Special Interests *

Do You Have Any Of The Following?

Since many general health conditions can be associated with eye health conditions it is important for us to have a clear understanding of your medical health and family history.

Do You Have A History Of?

Does Your Family Have A History Of?

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