Pre sight test questionnaire

Please fill out this questionnaire before your sight test so we can keep your time in the consulting room to a safe minimum.

Patient Information

Enter your name*

DATE OF BIRTH*

ADDRESS*

GP ADDRESS*

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Purpose: Understand visual demands and lifestyle needs.

Occupation

Do you drive? and if so, do you require spectacles while driving?

What hobbies do you have?

If you work, what does your job involve in relation to vision?

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Purpose: Gather details on the reason for the appointment and any visual symptoms.

Reason for booking

Are you worried about any aspect of your eyes or eyesight?

Do you struggle to see with your spectacles on?

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Purpose: Collect relevant health and hereditary information.

A. GENERAL HEALTH

Health conditions diagnosed

Do you take any medication?

Which medications have changed since your last visit?

B. FAMILY HISTORY

Any history of eye disorders in your family?

If yes, please specify the immediate family member(s) with a history of eye disorders.

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Purpose: Review past eye-related experiences and visual aids.Fields:

Have you ever been told you have any eye disorders/conditions?

Do you wear spectacles? (If yes, please bring them)

Do you wear contact lenses? (If yes, please bring them)

Thank you! Your submission has been received!

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