Adults Personal DetailsTitleNameGender Male Female Address(Required) Street Address City State Postcode Email(Required) PhoneMobileOccupationDate of birth DD slash MM slash YYYY Medicare number(Required)Card reference number(Required)Expiry Date(Required)Are you covered by Private Health Insurance(Required) Yes No Private Health Fund ProviderDo you have a Veteran Affairs Card? Yes No Do you have a Pension Card? Yes No GP's name(Required)GP's phone(Required)GP's addressPostcodeEmergency contact's nameEmergency contact's telephoneWhat's the reason for your visit today?Medical DetailsSince 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.Allergies Your History Family History Cancer Your History Family History Cataracts Your History Family History Diabetes Your History Family History Eye Injury Your History Family History Eye Surgery Your History Family History Glaucoma Your History Family History Heart Disease Your History Family History High Blood Pressure Your History Family History High Cholesterol Your History Family History Lazy Eye Your History Family History Macular Degeneration Your History Family History Retinal Disease Your History Family History Stroke Your History Family History OtherGeneral Eye Health DetailsIt 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: Burning Eyes Itchy Eyes Gritty Eyes Watery Eyes Dry Eyes Sore Eyes Red Eyes Floaters/Spots in Vision Flashing Lights in Vision Double Vision Sensitivity to Light/Glare Eye Strain Headaches Reading Difficulties Lifestyle DetailsIt 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.GLASSESDo you currently wear glasses?(Required) Yes No How old is your current pair?Do you have more than 1 pair of glasses? Yes No Do your glasses feel heavy on your face at the end of the day? Yes No CONTACT LENSESDo you currently wear contact lenses? Yes No Are your eyes comfortable at the end of the day? Yes No Are you interested in trialling contact lenses? Yes No OUTDOORS AND PROTECTIONDo 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? Less than 2 hours More than 2 hours Do you experience one or more of the following after extended use? Eye Fatigue Headaches Dry, sore or blurred eyes Neck or shoulder pain? Hobbies, Sports and Special InterestsPlease listHow did you hear about us?Please select Relative / Friend / Previous Patient Your GP Internet Search Our Website Facebook / Social Media Print Advert Other Future communicationAre you happy to receive occasional communications regarding eye health information and special offers by mail, email and sms? Yes No Thank you for entrusting us with your eyecarePrivacy Statement: Our practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide services to you. We may also use your personal contact information to send you information regarding eye health, eye care and eyewear, with your consent. By providing the information requested in the first three sections of this form we will be able to make an informed decision on how to best meet your eye care and eyewear needs. We may also need to provide some personal information to third party suppliers (such as providers of mail-out and electronic distribution services and eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy. I have ready and understood the privacy statement(Required) Yes CAPTCHA Δ Child Personal DetailsChild's Full Name(Required)Gender(Required) Male Female Child's Date of birth(Required) DD slash MM slash YYYY Parent/Guardian's Name(Required)Gender Male Female Address Street Address City State Postcode Parent/Guardian's Email(Required) Parent/Guardian's Mobile(Required)Child's Medicare number(Required)Card reference number(Required)Expiry Date(Required)Is your child covered by Private Health Insurance(Required) Yes No Private Health Fund ProviderGP's name(Required)GP's phone(Required)GP's addressPostcodeWhat's the reason for your visit today?(Required)Medical & Developmental HistoryHas your child previously been assessed by any of the following? Educational Psychologist Audiologist Speech Pathologist Occupational Therapist Ophthamologist Paediatrician Does your child currently wear glasses?(Required) Yes No Does your child have other health conditions we should be aware of?Was the pregnancy and birth free from complications? Yes No If No, provide detailsHow have the following developmental areas been progressing?General growth Good Fair Poor Walking Good Fair Poor Talking Good Fair Poor Hearing Good Fair Poor Social behaviour Good Fair Poor General coordination Good Fair Poor Name of schoolYear / LevelIs your child having difficulty with any of the following? Reading Writing Spelling Maths Behaviour If Yes, provide detailsHas your child repeated a grade? Yes No How would you rate your child's general present health? Good Fair Poor Please list any medications currently being taken by your childPlease detail important aspects of past health history: (Accidents, head/eye injuries, serious infections, high fevers, major surgeries etc)Eye HealthHas your child had a past visual examination? Yes No Previous visual examination date (approx)Reason for previous examinationResultsWhat were the previous treatments? Glasses/Contact Lenses Occlusion (eye patching) Vision Training Surgery Medication (e.g. eye drops or ointment) Details of previous treatmentsIs there any family history of “Eye Turn”, “Lazy Eye” or glasses? Yes No If yes, please describeHave other children in the family had visual issues?Do you observe any of the following? Unusual redness of eyes Unusual redness of lids Crusted lids Styes or sores on lids Excessive watering Present Health Unusual lid droopiness One eye turning IN or OUT with fatigue Excessive rubbing of eyes Frequent closing of one or both eyes Unusual clumsiness and bumping into objects If your child exhibits an “Eye Turn”, at what age was the “eye turn" first noticed?Is the turn always present or only occasionally?Could it be caused by any injury or illness? Yes No Does it turn” IN” or “OUT” In Out Is it always the same eye? Yes No Please bring any photos that show the turn to the appointment.Your AppointmentPlease bring to the examination any glasses that are presently worn by your child, or have been worn in the past. Please bring additional information, reports from other professionals etc. which you consider important to our understanding of your child.Do you need a detailed written report on the evaluation of your child’s eyesight and visual performance capabilities and optometric recommendations? Yes No Please list the names and addresses of people to whom you would like a copy of the report sent.How did you hear about us? Relative / Friend / Previous Patient Your GP Internet Search Our Website Facebook / Social Media Print Advert Other Future communicationAre you happy to receive occasional communications regarding eye health information and special offers by mail, email and sms? Yes No Thank you for entrusting us with your eyecarePrivacy Statement: Our practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide services to you. We may also use your personal contact information to send you information regarding eye health, eye care and eyewear, with your consent. By providing the information requested in the first three sections of this form we will be able to make an informed decision on how to best meet your eye care and eyewear needs. We may also need to provide some personal information to third party suppliers (such as providers of mail-out and electronic distribution services and eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy. I have read and understood the privacy statement(Required) Yes CAPTCHA Δ
