Welcome to the Practice (Adult)

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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.

Email *

Full Name *

Address *

Postcode *

Date of Birth *

YYYY

Mobile *

Medicare Number, Reference Number & Expiry *

Are you covered by Private Health Insurance? *

Yes

If you answered yes, who is the Provider Health Fund Provider?

GP's Name & Medical Practice *

What is your occupation? *

Were you referred to our office? *

Yes

If yes, whom may we thank for this referral?

What is the main reason for your visit today? *

Do you have an eyeturn or brain injury? If so, there are additional forms you need to complete on our website.

Yes. I need to complete an Eyeturn form

Yes. I need to complete the Brain Injury Vision Symptom Survey and Baseline Form

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MEDICAL HISTORY

Do you have any health conditions we should be aware of?

Have you ever had any blows or injuries to your head, eyes, or neck?

Yes

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If yes, please describe

Please list any medication you are currently taking

Please list any food or medication you are allergic to

VISUAL HISTORY

Is there any family history of visual problems? If yes, please specify

Are you currently wearing glasses or contact lenses?

Yes

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Are you having any problems with your current optical prescription?

Yes

Maybe

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If yes or maybe, please describe

Eye Teaming Ability: Have you reported the following?

Double vision

Headaches

Words moving or floating on the page

Cover or close one eye when reading

Poor reading posture

Nausea when doing visual tasks

Motion / car sickness

Other:

Focusing Ability: Have you noted the following?

Avoids small print

Become fatigued when reading

Blurred vision when reading

Eyestrain i.e. eyes burn, itch, tear, frequently red

Complain of frontal headache

Have a short attention span when reading

Hold a book very close

Frequently rubbing eyes when concentrating

Halos around lights

Need for bright light

Need for dim light

Eye Tracking Ability: Have you noted the following?

Lose place on the page often

Skip words and lines often

Poor reading comprehension

Apart from the above, is there anything else hindering your vision?

SCREEN USE

How many hours a day do you use the computer, tablet or phone?

Describe any visual symptoms you have experienced after using your computer, tablet or phone

Please list any questions, concerns you may have regarding your vision

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? *

Yes

Depending on the COVID situation in NSW, you and your child maybe required to wear a mask during the consultation. If you have your own mask, and observe the latest COVID guidelines.

Yes. I understand

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If telehealth is not possible. Do you feel that cancelling the session could have a negative impact on your physical and mental health?

Yes

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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. *

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

Maybe

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Submit

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