Please fill out the questionnaire below before your sight test Patient DetailsName First Last Date of Birth Day Month Year Date of Appointment Day Month Year Address Street Address Address Line 2 City County Post Code PhoneEmail GP Surgery Address Do you drive? Yes No If yes, what do you drive? Car HGV Occupation 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 Is most of your HOME computing done on: Laptop/Computer Tablet Smartphone None Approximate number of hours spent computing per day? What hobbies do you have? General HealthWhat health conditions have you been diagnosed with? None Diabetes High Cholesterol Raised Blood Pressure Lung Disease Hay-fever Arthritis Thyroid Disorder Depression or Anxiety Heart Disease Polymyalgia Other Other health conditions diagnosed with What medication do you take? None Insulin Diabetic tablets Thyroid tablets Pain relief Heart tablets Acid reflux medicine Anti-inflammatory tablets Antihistamines Statins Depression or anxiety tablets Blood pressure tablets Beta blockers Other Other medication taken Some medications are known to occasionally cause side effects involving the eyes. Do you take any of the following? Steroids (Prednisolone) Hydroxychloroquine Anti-acne treatment Methotrexate Hormonal anti-cancer drugs Chemotherapy medicine Family HistoryDo any of your close relations (mother/father, brother/sister, child) have an eye disorder (other than needing glasses) that you know of? Yes No If yes please specify who has/had what disease. Previous Eye HistoryDo 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 wear them for the sight test. Yes No Do you have any known eye disorders that require medical monitoring or treatment? None Macular Degeneration Cataracts developing Diabetic eye disease Glaucoma Other Other eye disorders What previous treatment or injury have you had to your eyes? None Cysts Styes Eyelid Surgery Lazy Eye Infection Cataract Removed Other Other previous eye treatment or injuries Reason For BookingDo you consider that your eyesight has altered since your last eye examination ? Yes No What problems are you having with your vision? (Please be specific)Do you struggle seeing with your spectacles on? (Please be specific)Are you troubled by more headaches than usual? If so, please explain as fully as you can.Please explain your reason for booking an eye examination appointment. Some useful information for your visit: You will understand that due to Covid 19 we’ve had to temporarily alter our working procedures. Please bear with us during this challenging period. We have a non-contact thermometer which we will use on your entry into the practice, and we will also insist on using our hand-sanitiser. Due to government guidelines the number of people allowed into the practice at any one time will be restricted. Please DO NOT ATTEND if you or anyone in your household is exhibiting signs of Covid 19 infection, however slight. These include a high temperature, a continuous cough or a loss or lessening of your sense of smell or taste. If you have had Covid 19 and recovered please allow at least 10 days before you consider making an eye examination appointment. Please do not turn up more than a couple of minutes before your allocated appointment time, this is to limit the amount of people in the shop. Please attend the practice wearing a face mask complying with the recommended specifications, this will be worn for the majority of your visit, if you don’t have one we have some available in the practice at the cost price of 0.50p. Please be alert to the need for social distancing within the practice, and any advice given by our staff members. You will understand that due to the nature of an eye examination we will be unable to observe the 2 metre distancing rule for certain parts of your visit. However, we will be wearing the appropriate Personal Protection Equipment to reduce any risk for you and us. It may be necessary to defer some of the less important investigative procedures we carry out until such time that we can relax the restrictions. For this reason we may ask you to return at a later date in order that we can complete any outstanding sections of your eye test. 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
