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New Adult Patient Questionnaire

New Adult Patient Questionnaire

  • Home New Adult Patient Questionnaire

    Select Your Appointment Location*
    Personal Details
    Date of Birth*
    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
    • Cancer
    • Cataracts
    • Diabetes
    • Eye Injury
    • Eye Surgery
    • Glaucoma
    • Heart Disease
    • High Blood Pressure
    • High Cholesterol
    • Lazy Eye
    • Macular Degeneration
    • Retinal Disease
    • Stroke
    General Eye Health Details
    It is important for us to understand any possible indicators of an eye health condition. Understanding your current symptoms will help us to effectively treat and/or manage your overall eye health.
    Do you experience any of the following?
    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.
    If Yes,
    Contact Lenses
    If Yes,
    If No,
    Outdoors and Protection
    Computers and Screen Devices
    Hobbies, Sports and Special Interests
    How did you hear about us?
    Future communication