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Welcome to the Practice (Adult)
Thank you for making an appointment with Eyes2Learn Optometrists. As a new patient, we need to ask some important questions about you . Completing this form prior to your appointment will maximise your examination time. If at any time you have any questions or concerns regarding your vision or treatment, please do not hesitate to contact us at
hello@eyes2learn.com
. Thank you for your cooperation.
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Email
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Your email
Full Name
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Your answer
Address
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Your answer
Postcode
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Mobile
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Your answer
Medicare Number, Reference Number & Expiry
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Your answer
Are you covered by Private Health Insurance?
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Yes
No
If you answered yes, who is the Provider Health Fund Provider?
Your answer
GP's Name & Medical Practice
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Your answer
What is your occupation?
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Your answer
Were you referred to our office?
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Yes
No
If yes, whom may we thank for this referral?
Your answer
What is the main reason for your visit today?
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Your answer
MEDICAL HISTORY
Do you have any health conditions we should be aware of?
Your answer
Have you ever had any blows or injuries to your head, eyes, or neck?
Yes
No
Clear selection
If yes, please describe:
Your answer
Please list any medication you are currently taking:
Your answer
Please list any food or medication you are allergic to:
Your answer
VISUAL HISTORY
Any history in your family of an eye turn resulting from a disease or other condition?
Yes
No
Clear selection
If yes, please explain:
Your answer
Was there any related trauma, disease or condition that preceded or accompanied the onset of the eye turn?
Yes
No
Clear selection
If yes, please explain:
Your answer
Are you prone to infections?
Yes
No
Clear selection
Are there any chronic problems like ear infections, asthma, hay fever, allergies?
Yes
No
Clear selection
If yes, please list:
Your answer
Has a neurological evaluation ever been performed?
Yes
No
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If yes, by whom? What were the results?
Your answer
At what age was it first noticed or suspected that an eye was turning?
Your answer
Did the eye begin turning suddenly or gradually?
Suddenly
Gradually
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Does the eye turn in, out, up, down? Check all that apply
In
Out
Up
Down
Is it always the same eyes that turn?
Yes
No
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If yes, which eye?
Right eye
Left eye
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Is the eye turn always present?
Yes
No
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If no, under what conditions is it present?
Your answer
Does the eye always turn in the same amount?
Yes
No
Clear selection
If no, explain:
Your answer
Do you notice if the eye turns more when you look
Yes
No
Up close
In the distance
To your left
To your right
Up
Down
Yes
No
Up close
In the distance
To your left
To your right
Up
Down
Clear selection
Does one pupil ever appear to be larger than the other?
Yes
No
Clear selection
Do you ever notice one or both eyes shaking rapidly?
Yes
No
Clear selection
Do you experience any of the following?
Headaches
Double vision
Blurred vision
Eyestrain i.e. tired or hurt
Motion sickness / car sickness
Red or blood shot eyes
Watery eyes
Bothered by light
Closing or covering an eye to see better
Holding paper closer to read or write
Head tilt
Confusion of letters or words
Skipping or omitting words
Loss of place when reading
Need to use finger to keep place
Poor reading comprehension
Write or print poorly
Fatigue easily
Difficulty with short term memory
Difficulty with long term memory
Short attention span / loss of interest
Difficulty attending to details
Poor awkward general motor coordination
Poor fine motor coordination
Difficulty judging distances
Difficulty driving
Dislike / avoid sports
Difficulty hitting or judging moving targets during sports
Apart from the above, is there anything else hindering your vision?
Your answer
Do you feel your vision limits your potential or daily activities in any way?
Yes
No
Clear selection
If yes, please explain:
Your answer
PREVIOUS TREATMENTS
Have you ever had a previous visual evaluation?
Yes
No
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When was the evaluation? What was the results and recommendation?
Your answer
Were glasses, contact lenses or other optical devices recommended or prescribed?
Yes
No
Clear selection
If yes, explain what they are:
Your answer
Are they worn?
Yes
No
Clear selection
If yes, when do you wear them? If no, why not?
Your answer
Does the eye turn less when the prescription is worn?
Yes
No
Unsure
Clear selection
Have you been told that you have amblyopia (lazy eye)?
Yes
No
Clear selection
Has there been any treatment using an eye patch?
Yes
No
Clear selection
If yes, please describe when patching was started, how the patching was done, including the age it started, the eye patched, the duration of treatment and an estimate of the results:
Your answer
Has there been any surgical treatment?
Yes
No
Clear selection
If yes, describe the surgery, including the age surgery was performed, the number of operations, the eye(s) operated on, and an estimate of the cosmetic and subjective results:
Your answer
Was the surgeon satisfied with the results of the surgery?
Yes
No
Clear selection
If no, explain:
Your answer
Were you satisfied with the results of the surgery?
Yes
No
Clear selection
If no, please explain:
Your answer
Have surgical results been maintained?
Yes
No
Clear selection
If no, please explain:
Your answer
Has there been any visual therapy?
Yes
No
Clear selection
If yes, who was the doctor? Could you describe the visual therapy, including duration, the age at which it started and an estimate of results:
Your answer
Are you here for a second opinion regarding surgery or other treatment?
Yes
No
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LEISURE TIME
Describe the type of activities that comprise majority of your spare time
Your answer
How many hours of TV do you watch per day?
Your answer
Do you feel your vision limits or prevents you from participating in any activities?
Yes
No
Clear selection
If yes, please explain what and how:
Your answer
Please list any other information that you feel would be helpful / important in our evaluation and/or treatment:
Your answer
It is often beneficial for us to discuss examination results and to exchange information with other professionals involved in your care. Do you agree to permit information from your examination to be forwarded to other health care providers upon their written requests or upon the recommendation of EYES2LEARN OPTOMETRISTS when it is necessary for the treatment of your visual condition?
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Yes
No
We request a minimum of 24 hours notice if you are unable to keep this appointment. Please be on time for your evaluation so that we may have the maximum opportunity to evaluate your visual status.
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Yes. I understand
Other:
How did you hear about us?
Relative/Friend/Previous Patient
Internet Search/ Our Website
Social Media
Print Advert
Other:
Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email or sms?
Yes
No
Maybe
Clear selection
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