Important information, please read

Please also forward or bring any relevant reports regarding your condition and treatment.
If Work Cover or CTP Insurance or similar will be involved in your billing we will need details including whether your consultation has already been approved.
Please also refer to our insurance and billing information.

The following form features a ‘Save and Continue’ option.

This enables you to save your progress and return later without starting from scratch. You can locate this option at the bottom of the form. After selecting it, you can either receive a link directly or provide your email address to have the link sent to you. This allows you to resume completing the form at your convenience.

New Neuro-Optometry Patients Questionnaire

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

Your Name(Required)

Title First Name (as on Medicare card) Last Name (as on Medicare card)

Known As

Name you preferred to be called

Date of Birth(Required)

Medicare Number

Reference Number

Expiry (valid to)

Residential Address

Street Address Address Line 2 Suburb State Postal Code Country

Different Postal Address?

Yes

Postal Address

Street Address Address Line 2 Suburb Postal Code Country

Landline Phone

Mobile Phone

Work

Your Email Address(Required)

Email Address Confirm Email Address

How do you want to be contacted?(Required)

Landline Phone

Mobile Phone

Work Phone

Text Message

Best Time to Call You

Billing

Has billing for your Optometric care been pre-approved by any of the following?

WorkCover

CTP

Other

Please answer

Yes

Not sure

If applicable, your case number?

Case manager

Contact details of case manager

Relevant to your visual needs

Occupation

What hobbies or sports do you participate in?

Do you use any of the following?

Please select all that apply

Desktop computer

Laptop computer

Tablet or iPad

Mobile phone

Gaming device

Kindle or E-reader

Visual History

Were you referred for an Optometric assessment due to your medical condition?

E.g. ABI, concussion or vertigo

Yes

Who referred you?

Please include Clinic name

When was your last visual examination?

Approximately

By whom and where?

Do you use any of the following?

Prescribed glasses

Prescription sunglasses

Non-prescription sunglasses

Contact lenses

Over the counter magnifying glasses

Non-prescription blue-light blocking glasses

Non-prescription neurological tinted glasses

Safety glasses

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

including eye surgery & eye

Do you use eye drops?

Yes

Please list those those you use

Current visual symptoms

Are you also experiencing any of the following?

Sudden loss of vision

Regular headaches (not related to when using your eyes)

Floating spots in your vision

Flashing lights in your vision

Eye strain

Burning or itchy eyes

Red eyes

Distorted (wavy or wobbly) vision

Other symptoms not listed

Family history

Do you have a family history of any of the following?

Glaucoma

Macular degeneration

Cataract

Diabetes

Retinal detachment

Retinitis Pigmentosa

Strabismus (turned eye)

Amblyopia (lazy eye)

Medical history

Name of your GP

Medical Clinic

Please list any other medical or allied health professionals involved in your care?

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

Do you have or have experienced any of the following?

Type

List

Other conditions you feel are relevant

BIVSS Checklist and Survey

BIVSS Brain Injury Vision Symptom. Please fill this out even if you haven’t experienced a brain injury.

Have you ever sustained a brain injury?

Yes

Cause of injury

In which year did your brain injury happened?

Year or approximate years you’ve had the injury

I have had a medical diagnosis of brain injury

Yes

I sustained a brain injury without medical diagnosis

Yes

Eyesight clarity

Distance vision blurred and not clear – even with lenses

Please select a number

Near vision blurred and not clear – even with lenses

Please select a number

Clarity of vision changes or fluctuates during the day

Please select a number

Poor night vision / can’t see well to drive at night

Please select a number

Visual Comfort

Eye discomfort / sore eyes / eyestrain

Please select a number

Headaches or dizziness after using eyes

Please select a number

Eye fatigue / very tired after using eyes all day

Please select a number

Feel "pulling" around the eyes

Please select a number

Doubling

Double vision – especially when tired

Please select a number

Have to close or cover one eye to see clearly

Please select a number

Print moves in and out of focus when reading

Please select a number

Light sensitivity

Normal indoor lighting is uncomfortable – too much glare

Please select a number

Outdoor light too bright – have to use sunglasses

Please select a number

Indoors fluorescent lighting is bothersome or annoying

Please select a number

Dry eyes

Eyes feel "dry" and sting

Please select a number

"Stare" into space without blinking

Please select a number

Have to rub the eyes a lot

Please select a number

Depth perception

Clumsiness / misjudge where objects really are

Please select a number

Lack of confidence walking / missing steps / stumbling

Please select a number

Poor handwriting (spacing, size, legibility)

Please select a number

Peripheral vision

Side vision distorted / objects move or change position

Please select a number

What looks straight ahead – isn’t always straight ahead

Please select a number

Avoid crowds / can’t tolerate "visually–busy" places

Please select a number

Reading

Short attention span / easily distracted when reading

Please select a number

Difficulty / slowness with reading and writing

Please select a number

Poor reading comprehension / can’t remember what was read

Please select a number

Confusion of words / skip words during reading

Please select a number

Lose place / have to use finger not to lose place when reading

Please select a number

Consent

Communications Consent(Required)

Do you consent to us sending you occasional communications including appointment reminders, eye health information & promotions relevant to you via email, SMS or post?

Yes

Your signature

Date(Required)

Neuro-Optometry Patient

Important information, please read

The following form features a ‘Save and Continue’ option.

New Neuro-Optometry Patients Questionnaire

Billing

Relevant to your visual needs

Visual History

Current visual symptoms

Family history

Medical history

BIVSS Checklist and Survey

Eyesight clarity

Visual Comfort

Doubling

Light sensitivity

Dry eyes

Depth perception

Peripheral vision

Reading

Consent

Make an appointment

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