New Adult Info - optometry@cooroy

optometry@cooroy
optometry@cooroy
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New Adult Info

By filling out this form before your appointment you will be giving us valuable information to assist us with your examination.  

WE ARE CURRENTLY HAVING OCCASIONAL ISSUES WITH ONLINE FORMS
If your form has gone through properly you will receive a reply email shortly after submitting.

You may prefer to print out our pdf version & bring this with you instead.
This questionnaire is to be used by all new patients 16 years or older.

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MrMsDr
MrsMissOther
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RESIDENTIAL ADDRESS

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MAILING ADDRESS (if different to your residential address)

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PHONE & EMAIL CONTACT DETAILS

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Mobile PhoneWork phone
SMS / TextEmail
Home phone
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ENTITLEMENTS

NonePension
Veterans AffairsHealth Care Card
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YesNoNot sure
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RELEVANT TO YOUR VISUAL NEEDS

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 Desktop Computer Mobile Phone
 Laptop Computer Gaming Device
 Tablet or iPad Kindle or E-reader
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VISUAL HISTORY

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Medicare will generally provide a full rebate for a comprehensive consultation only once every 36 months if you are under 65 yrs of age or once every 12 months for those 65 yrs & older. Full rebates are available more frequently to those with a progressive eye disorder, diabetics or when referred by another optometrist.

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 Prescribed glasses Magnifier glasses
 Prescription sunglasses Low vision aids
 Non prescription sunglasses Safety glasses
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YesNo

YesNo

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YesNo

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 Short Sightedness
 Long Sightedness
 Lazy eye or turned eye
 Colour vision deficiency
 Allergic eye conditions
 Eye disease/s
 Eye surgery
 Eye injury
 Retinal detachment or tear
 Blindness
 Cataracts
 Glaucoma
 Macular degeneration
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 Reading or near difficulties
 Blurred vision up close
 Distance vision difficulties
 Blurred vision for distance
 Eye strain
 Gritty or dry eyes
 Burning eyes
 Itchy eyes
 Sore eyes
 Red eyes
 Regular headaches
 Floating spots in your vision
 Flashing lights in your vision
 Double vision
 Distortion to your vision
 Sudden loss of vision
 Sensitivity to light
 Glare issues
 Motion sickness or vertigo
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 Glaucoma
 Macular degeneration
 Cataract
 Retinal detachment
 Diabetes
 Retinitis Pigmentosa
 Strabismus (turned eye)
 Amblyopia (lazy eye)
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MEDICAL HISTORY

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 Diabetes Concussion
 High blood pressure Stroke
 Heart problems Autoimmune disease
 Allergies / asthma Thyroid Problems
 Cancer Multiple Sclerosis
 Arthritis Plaquenil use
 Head injury Methotrexate use
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REFERRAL

 Our location Facebook
 Family Signage in town
 Friend Newspaper advert
 Doctor Newspaper editorial
 Teacher Yellow pages
 Other Professional Local phone directory
 Internet search Other
 Our website
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PRIVACY STATEMENT


62 Maple Street
Cooroy Qld 4563
Ph:   07 5442 5555
optometry@cooroy
Ph:   07 5442 5555
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