Please fill out the questionnaire below before your sight test 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 DetailsName Date of Birth Day Month Year Address Street Address Address Line 2 City County Post Code TelephoneMobileEmail GP surgery GP address What is your occupation? Do you drive? Yes wearing spectacles Yes without spectacles No If yes, do you drive an HGV Yes No Other 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) Is most of your WORK computing done on: Laptop/Computer Tablet Smartphone None Reason For Booking Please explain your reason for booking an eye examination appointmentAre you worried about any aspect of your eyes or eyesight? (Please be specific)Has your vision noticeably changed since your last eye examination? Yes No Do you struggle to see with your spectacles on? (Please be specific)Are you troubled by more headaches than usual? Yes No General HealthPlease list the health conditions you have been diagnosed with: Do you take any medication? Yes No 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 HistorySome eye conditions are hereditary. Is there a history of any specific eye disorder in your family? (other than needing glasses) Mother/father? Yes No If yes please specify who has/had what disease. Brother/sister? Yes No If yes please specify who has/had what disease. Child Yes No If yes please specify who has/had what disease. Previous Eye HistoryHave you ever been told you have any eye disorders/conditions? Yes No If so please list the conditions: Do you wear spectacles?If yes please bring them to the eye examination appointment. Yes No Do you wear contact lenses?If yes please do NOT attend the sight test with them in. Yes No 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.CAPTCHA Please fill out the questionnaire below before your contact lens appointment Name First Last Email PhoneDate of Birth Day Month Year Date of Last Sight TestLeave this blank if you haven't had a test with us before. Day Month Year Do You Drive? Yes No Do You Smoke? Yes No How is your general health? Are you on any medication? (If yes, please specify) Are You Diabetic? Yes No Type Current Contact Lens Type Soft Rigid (Gas Permeable) How often are your contact lenses replaced? Solution Name Wear Time Every Day Some Days Occasionally How Many Hours 5-7 Hours 8-12 Hours Longer ComfortPlease indicate with 1 being poor to 5 being good 1 2 3 4 5 Does comfort vary/change? Yes No Vision (Distance)Please indicate with 1 being poor to 5 being good 1 2 3 4 5 Vision (Near)Please indicate with 1 being poor to 5 being good 1 2 3 4 5 Do you use a computer? Yes No How many hours a day on average? Have we or any other Optician advised you about Dry Eye and methods to improve it? Yes No Do we need to know anything else?CAPTCHA
