If you answered yes, who is the Provider Health Fund Provider?
Your answer
GP's Name & Medical Practice *
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What is your occupation? *
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Were you referred to our office? *
If yes, whom may we thank for this referral?
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What is the main reason for your visit today? *
Your answer
MEDICAL HISTORY
Do you have any health conditions we should be aware of?
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Have you ever had any blows or injuries to your head, eyes, or neck?
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If yes, please describe
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Please list any medication you are currently taking
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Please list any food or medication you are allergic to
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Current diet
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Describe your current state of health
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VISUAL HISTORY
When and where was your last vision examination?
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What were the results and recommendation?
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Are you currently wearing glasses or contact lenses?
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Are you having any problems with your current optical prescription?
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If yes or maybe, please describe
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Is there any family history of visual problems? If yes, please specify
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Eye Teaming Ability: Have you reported the following?
Focusing Ability: Have you noted the following?
Eye Tracking Ability: Have you noted the following?
Visual Processing Abilities: Have you noted the following?
Apart from the above, is there anything else hindering your vision?
Your answer
SCREEN USE
How many hours a day do you use the computer, tablet or phone?
Your answer
Describe your computer setup i.e. distance from eyes to the screen, is the screen above or below eye level? How far away is the keyboard?
Your answer
Describe any visual symptoms you have experienced after using your computer, tablet or phone
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Do you experience any of the following lighting problems at work?
Please list any questions, concerns you may have regarding your vision
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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? *
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. *
How did you hear about us?
Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email or sms?
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