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.

Full name *
Preferred name
Date of birth *
Who referred you and why?
Complete Medicare no.
Position
Expiry
Please check here to give us permission to contact Medicare if we need to clarify information regarding item numbers
Private Health Fund
Home Address
Suburb
Postcode
Email Address *
Home telephone number
Mobile number
Occupation

Visual History

Are you experiencing any eye or vision problems at this point in time?
Have you ever worn glasses? Please Detail
Have you ever worn contact lens? 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
Does your job include using a computer terminal?
Hours per day?
Do you have vision problems with sport/hobbies?
Tilting head when reading?

Do you experience any of the following?

Visual Headaches
YesNo
Eyes hurt/tired/frequently red
YesNo
Closing/covering one eye?
YesNo
Blurred Vision Far
YesNo
Double Vision
YesNo
Blurred at Near
YesNo
Eye turns in or wander out?
YesNo

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

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

Health History

How is your general health?
ExcellentGoodFairPoor
Date of your last GP examination
Name of GP
Address of your GP
What kind of exercise do you do?
Indicate any current medications
Indicate any allergies
Do you smoke?
If so how many per day?

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

High Blood Pressure
YesNoRelative
Elevated Cholesterol
YesNoRelative
Diabetes
YesNoRelative
Arthritis
YesNoRelative
Asthma
YesNoRelative
Depression/Mental Illness
YesNoRelative
Migraine/Headache
YesNoRelative
Heart disease
YesNoRelative
Thyroid disease
YesNoRelative
Skin disease
YesNoRelative
Head injury
YesNoRelative
Drug sensitive/allergies
YesNoRelative
Weight loss/gain
YesNoRelative
Cancer
YesNoRelative
Epilepsy
YesNoRelative
Multiple Sclerosis
YesNoRelative
Please detail any other history that you feel may be helpful to us in providing you with Eyecare

Digital Retinal Imaging and OCT scanning is likely to be recommended in which case there will be a fee of $75 ($65 for pension card holders and health care card holders)