New Adult Info - optometry@cooroy

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Behavioural Optometry
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Home
About Us
- Our Team
Behavioural Optometry
Services
Products
- Eyewear
- Contact Lenses
Contact

Home
About Us
- Our Team
Behavioural Optometry
Services
Products
- Eyewear
- Contact Lenses
Contact

New Adult Info

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

If you would rather fill out a paper version of our questionnaire please go to this page and download a pdf version.

This questionnaire is to be used by all new patients 16 years or older.

Today's date

Title

MrMsDr
MrsMissOther
Tip

First Name (required field)*

Last Name (required field)*

Known as

Date of birth (required field)*

RESIDENTIAL ADDRESS

Address

Suburb / Town

Post Code

MAILING ADDRESS (if different to your residential address)

Address

Suburb / Town

Post Code

PHONE & EMAIL CONTACT DETAILS

Mobile phone

Home Phone

Work Phone

Email (required field)*

Repeat Email (required field)*

Preferred 1st method of contact*

Mobile PhoneWork phone
SMS / TextEmail
Home phone
Tip

ENTITLEMENTS

Do you have any of the following entitlements?

NonePension
Veterans AffairsHealth Care Card
Tip

Do you have private health insurance extras?

YesNoNot sure
Tip

If yes, which Health Fund?

RELEVANT TO YOUR VISUAL NEEDS

Occupation

Do you participate in sports or other hobbies? If so, please list.

Do you use any of the following? (List all that apply)

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

VISUAL HISTORY

What is the main reason for your visit with us? (required field)*

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.

When was your last visual examination (approx)?

By whom & where?

Do you use any of the following?

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

Do you wear contact lenses?

YesNo

If no, are you interested in learning more about contact lenses?

YesNo

List any eye/vision treatment other than glasses or contact lenses?

Do you use any eye drops?

YesNo

If yes, please list the drops you use (or bring a list with you)

Do you have or have experienced any of the following?

Short Sightedness
Long Sightedness
Lazy eye or turned eye
Colour vision deficiency
Eye disease/s
Eye injury
Retinal detachment or tear
Eye surgery
Blindness
Cataracts
Glaucoma
Macular degeneration
Allergic eye conditions
Tip

Do you experience any of the following?

Burning eyes
Itchy eyes
Gritty or dry eyes
Sore eyes
Red eyes
Eye strain
Floating spots in your vision
Flashing lights in your vision
Regular headaches
Distance vision difficulties
Blurred vision for distance
Reading or near difficulties
Blurred vision up close
Double vision
Sudden loss of vision
Sensitivity to light
Glare issues
Motion sickness or vertigo
Tip

Do you have a family history of any of the following

Glaucoma
Macular degeneration
Cataract
Retinal detachment
Diabetes
Tip

MEDICAL HISTORY

Name of your GP & Medical Clinic

Please list any medications you are taking (including natural supplements)

Do you have or have experienced any of the following?

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

REFERRAL

How did you find out about our practice? Select all that apply.

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

If you were referred, whom may we thank?

PRIVACY STATEMENT

I acknowledge that I have read and agreed to the privacy statement below (required field)*

PRIVACY STATEMENT: Our practice respects your privacy & will comply with the Privacy Act & Australian Privacy Principles when handling your personal information. The information provided on this form helps us to make informed decisions on how to best meet your eyecare and eyewear needs. We may use your personal contact information to send you information regarding eye health, eyecare and eyewear, with your consent. We may also need to provide some personal information to third party suppliers (such as mail-out and electronic distribution services & eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). Please contact us if you would like to know more about how we handle personal information.

I agree

62 Maple Street

Cooroy Qld 4563

Ph: 07 5442 5555