New Adult Info - [email protected]

optometry@cooroy
optometry@cooroy
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New Adult Info

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

MrMrsMissMasterDr
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Residential Address

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Mailing Address (if different to your residential address)

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Phone & Email Contact Details

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Mobile PhoneSMSHome phoneWork phoneEmail
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Entitlements

Veterans AffairsPensionHealth Care CardNone
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YesNoNot sure
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Relevant to your visual needs

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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.

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 Prescribed glasses Non prescription sunglasses Contact lenses
 Prescription sunglasses Off the shelf magnifying glasses Low vision aids
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 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
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 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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 Glaucoma Cataract Diabetes
 Macular degeneration Retinal detachment
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 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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62 Maple Street
Cooroy Qld 4563
Ph:   07 5442 5555
optometry@cooroy
Ph:   07 5442 5555
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