New Patient Patient QuestionnairePatient Questionnaire To ensure we have accurate, up-to-date records, (and for new patients where we have no prior history of your eyecare), we would appreciate you completing the following. This will assist the optometrist in determining how best to proceed with your examination.Title- Select -MrMrsMsMissDrOtherFirst NameLast NameHome AddressContact PH - HomeMobileBusinessEmailDOB:Do you wear glasses currently? Yes NoIf so, are they Single Vision Multifocal BifocalAre there any times you would like to be able to see well, but not wear your glasses? Yes No N/ADo you wear contact lenses currently? Yes NoType (if known)Do you Smoke? Yes NoIf so, how many per day?Do you currently take any prescription medications? Yes NoIf so, please list Do you have, or has anyone in your family had Diabetes Yes NoIf so, who?High Blood Pressure Yes NoIf so, who?Glaucoma Yes NoIf so, who?Macular Degeneration Yes NoIf so, who?Do YOU ever have any of the following:Sore, dry eyes Yes NoIf so, when?Watery eyes Yes NoIf so, when?Headaches Yes NoIf so, when?Double Vision Yes NoIf so, when?Blurred vision Yes NoIf so, when?What is the Main Reason for having an Eye Examination with Us today? Please note here-Please rate each of the following activities: 1 = I never do this, 10 = I do this everydayUse a computer at work - Select -12345678910Use a computer at home- Select -12345678910Use a Smartphone or tablet for email or online searches- Select -12345678910Read for pleasure- Select -12345678910Do crafts eg sewing, knitting, model-making - Select -12345678910Do outdoor activities eg hiking, running, gardening - Select -12345678910Sports eg basketball, cricket, tennis, squash - Select -12345678910Water Sports eg diving, fishing, surfing, swimming- Select -12345678910Submit Form
