Questionnaire Test | Dominic Tunnell Opticians

Pre Sight Test Questionnaire:

Please complete and return this form well in advance of your visit. It will enable us to keep your time in the consulting room to a safe minimum.

Patient Details

Name

Telephone

Mobile

Email

GP surgery

GP address

What is your occupation?

What hobbies do you have?

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

(e.g. computer screen, operating machinery, detailed close work, the need for safety spectacles)

Reason For Booking

Please explain your reason for booking an eye examination appointment

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

(Please be specific)

Do you struggle to see with your spectacles on?

(Please be specific)

General Health

Please list the health conditions you have been diagnosed with:

If we’ve seen you previously, which medications have CHANGED since your last visit here?

If we don’t have a record of your medication, please list here, or you may wish to bring a copy of your GP prescription with you to your appointment:

Family History

Some eye conditions are hereditary. Is there a history of any specific eye disorder in your family?

(other than needing glasses)

If yes please specify who has/had what disease.

Previous Eye History

If so please list the conditions:

Some useful information for your visit:

Despite changing government advice, masks will still be worn in the consulting rooms. Please bring a face covering with you. Please DO NOT ATTEND if you have any symptoms of COVID-19, however slight. Thank you from all the team at Tunnells.

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