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Adults Form

1. Personal Details

Title

First Name

Surname

Sex

Date of birth

Occupation

Address

Suburb

Home Phone

Mobile

Email

When was your last eye examination?

Private health insurance?

If so which provider?

What is the main reason for your visit?

Do you identify as Aboriginal or Torres Strait Islander?

2. Medical Details

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.

Please select from below if any apply:

Allergies

You (Yes) Family (Yes)

Cancer

You (Yes) Family (Yes)

Cataracts

You (Yes) Family (Yes)

Diabetes

You (Yes) Family (Yes)

Eye Injury

You (Yes) Family (Yes)

Eye Surgery

You (Yes) Family (Yes)

Glaucoma

You (Yes) Family (Yes)

Heart Disease

You (Yes) Family (Yes)

High Blood Pressure

You (Yes) Family (Yes)

High Cholesterol

You (Yes) Family (Yes)

Lazy Eye

You (Yes) Family (Yes)

Macular Degeneration

You (Yes) Family (Yes)

Retinal Disease

You (Yes) Family (Yes)

Stroke

You (Yes) Family (Yes)

Other health conditions

Please list your current medications

Please list any allergies to medications

3. General Eye Health Details

It is important for us to understand any possible indicators of an eye health condition. Understanding your current symptoms will help us to effectively treat and/or manage your overall eye health.

Do you experience any of the following?

Itchy eyes

Yes

Gritty eyes

Yes

Watery eyes

Yes

Sore eyes

Yes

Red eyes

Yes

Floaters/spots in vision

Yes

Flashing lights in vision

Yes

Double vision

Yes

Sensitivity to light/glare

Yes

Eye strain

Yes

Headaches

Yes

Reading difficulties

Yes

Other

4. How did you hear about us?

Please select

Internet search/our website Facebook/social media Your GP Walking past Other

Or a relative/friend/previous patient

5. Future Communication

Are you happy to receive occasional communications including appointment reminders and information on eyecare and eyewear via mail, email and sms?

Please select

Yes No