Langwarrin:
03 9776 7702
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Age-related Macular Degeneration (AMD)
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New Adult Patient Questionnaire
New Adult Patient Questionnaire
Home
New Adult Patient Questionnaire
What is the main reason for your visit today?
Personal Details
Mr
Mrs
Miss
Ms
Dr
Prof
Sex*
Male
Female
Date of Birth*
Do you have Private Health Insurance?*
Yes
No
Do you have a Pension / Concession Card?*
Yes
No
Medical Details
Since many general health conditions can be associated with eye health conditions it is important for us to have a clear understanding of your medical health and family history.
Conditions
Your History
Family History
Allergies
Yes
No
Yes
No
Cancer
Yes
No
Yes
No
Cataracts
Yes
No
Yes
No
Diabetes
Yes
No
Yes
No
Eye Injury
Yes
No
Yes
No
Eye Surgery
Yes
No
Yes
No
Glaucoma
Yes
No
Yes
No
Heart Disease
Yes
No
Yes
No
High Blood Pressure
Yes
No
Yes
No
High Cholesterol
Yes
No
Yes
No
Lazy Eye
Yes
No
Yes
No
Macular Degeneration
Yes
No
Yes
No
Retinal Disease
Yes
No
Yes
No
Stroke
Yes
No
Yes
No
Lifestyle Details
It is important for us to understand how you live your life in order to provide you with a tailored eyewear solution to suit your needs and lifestyle. Please answer the questions below to give us an insight into yours.
Glasses
Do you currently wear glasses?
Yes
No
Do you have more than 1 pair of glasses?
Yes
No
Do you have any concerns with your current glasses (e.g. heavy/weight, soreness)?
Yes
No
Contact Lenses
Do you currently wear contact lenses?
Yes
No
Are your eyes comfortable at the end of the day?
NA
Yes
No
Are you interested in trialling contact lenses?
NA
Yes
No
Would you like to discuss options for contact lenses at your appointment?
NA
Yes
No
Outdoors and Protection
Do you spend a lot of time outdoors?
Yes
No
Do you have a problem with glare?
Yes
No
Do you wear prescription sunglasses?
Yes
No
Do you require safety glasses for your occupation or sporting activities?
Yes
No
Computers and Screen Devices
Does your work require computer use?
Yes
No
Do you have a dedicated pair of computer/office spectacles?
Yes
No
How long do you spend per day on computers or other screen-based devices?
0-30 minutes
30 minutes - 1 hour
1 - 2 hours
2 - 4 hours
4 - 8 hours
8+ hours
Do you experience one or more of the following after extended use?
Eye fatigue
Yes
Headaches
Yes
Dry, sore or blurred eyes
Yes
Neck or shoulder pain
Yes
How did you hear about us?
Who?
Relative
Friend
Previous Patient
Other
Where?
Facebook
Instagram
social media
Print advertisement
Local shopping centre
GP or other Health Professional
Other
Future communication
Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email and sms?
Yes
No
