New Adult Info - [email protected]

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Behavioural Optometry
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Home
About Us
- Our Team
Behavioural Optometry
Services
Products
- Eyewear
- Contact Lenses
Contact
- New Patients

Home
About Us
- Our Team
Behavioural Optometry
Services
Products
- Eyewear
- Contact Lenses
Contact
- New Patients

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New Adult Info

Contact

This questionnaire is to be used by all new patients 16 years or older.

Title

MrMrsMissMasterDr
Tip

First Name*

Last Name*

Known as

Date of birth*

Residential Address

Address

Suburb

Post Code

Mailing Address (if different to your residential address)

Address

Suburb

Post Code

Phone & Email Contact Details

Mobile phone

Home Phone

Work Phone

Preferred 1st method of contact*

Mobile PhoneSMSHome phoneWork phoneEmail
Tip

Entitlements

Do you have any of the following entitlements?*

Veterans AffairsPensionHealth Care CardNone
Tip

Do you have private health insurance extras? *

YesNoNot sure
Tip

If yes, which Health Fund?

Relevant to your visual needs

Occupation

Sports / Hobbies / Electronic Devices used

What is the main reason for your visit today?*

Visual & Medical History

Medicare will generally provide a full rebate for a comprehensive consultation only once every 36 months if you are under 65 yrs of age or once every 12 months for those 65 yrs & older. Full rebates are available more frequently to those with a progressive eye disorder, diabetics or when referred by another optometrist.

When was your last visual examination (approx)?

By whom & where?

Do you use any of the following?

Prescribed glasses Non prescription sunglasses Contact lenses
Prescription sunglasses Off the shelf magnifying glasses Low vision aids
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List any eye/vision treatment other than glasses or contact lenses?

Do you have or have experienced any of the following?

Short Sightedness High blood pressure
Lazy eye or turned eye Heart problems
Colour vision deficiency Allergies / asthma
Eye diseases Cancer
Eye injury Arthritis
Eye surgery Head injury (inc. concussion)
Blindness Stroke
Cataracts Autoimmune disease
Glaucoma Thyroid Problems
Macular degeneration Multiple Sclerosis
Diabetes Plaquenil or methotrexate use
Tip

Do you experience any of the following?

Burning eyes Reading or near difficulties
Itchy eyes Distance vision difficulties
Gritty or dry eyes Double vision
Sore eyes Sudden loss of vision
Red eyes Sensitivity to light
Eye strain Glare issues
Floating spots in your vision Blurred vision for distance
Flashing lights in your vision Blurred vision up close
Regular headaches Motion sickness or vertigo
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Do you have a family history of any of the following

Glaucoma Cataract Diabetes
Macular degeneration Retinal detachment
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How did you find out about our practice?

Our location Our website
Family Facebook
Friend Newspaper advert
Doctor Newspaper editorial
Teacher Yellow pages
Other Professional Local phone directory
Internet search Other
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If you were referred, whom may we thank?

I acknowledge that I have read and agreed to the privacy statement below*

PRIVACY STATEMENT: Our practice respects your privacy & will comply with the Privacy Act & Australian Privacy Principles when handling your personal information. The information provided on this form helps us to make informed decisions on how to best meet your eyecare and eyewear needs. We may use your personal contact information to send you information regarding eye health, eyecare and eyewear, with your consent. We may also need to provide some personal information to third party suppliers (such as mail-out and electronic distribution services & eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). 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 agree

62 Maple Street

Cooroy Qld 4563

Ph: 07 5442 5555