Neuro-Optometry Patient

Important information, please read

• Please also forward or bring any relevant reports regarding your condition and treatment.
• If Work Cover or CTP Insurance or similar will be involved in your billing we will need details including whether your consultation has already been approved.
• Please also refer to our insurance and billing information.

• You must fill out the digital form below before your appointment date.
• If you prefer to fill out the form by hand, you can download and print the Neuro-Optometry Questionnaire PDF to bring to your appointment.

New Neuro-Optometry Patients Questionnaire

By filling out this form you will be giving us valuable information to assist us with your examination.

Your Name(Required)

Title Mr.Mrs.MissMs.Dr.Prof.Rev.None First Name (as on Medicare card) Last Name (as on Medicare card)

Known As

Name you preferred to be called

Date of Birth(Required)

Day

Month

Year

Medicare Number

Reference Number

Expiry (valid to)

Residential Address

Street Address Address Line 2 Suburb State Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Different Postal Address?

Yes

No

Postal Address

Street Address Address Line 2 Suburb Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Landline Phone

Mobile Phone

Work

Your Email Address(Required)

Email Address Confirm Email Address

How do you want to be contacted?(Required)

Landline Phone

Mobile Phone

Work Phone

Email

Text Message

Best Time to Call You

Select a time8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm

Billing

Has billing for your Optometric care been pre-approved by any of the following?

WorkCover

CTP

Other

Please answer

Yes

No

Not sure

If applicable, your case number?

Case manager

Contact details of case manager

Relevant to your visual needs

Occupation

What hobbies or sports do you participate in?

Do you use any of the following?

Please select all that apply

Desktop computer

Laptop computer

Tablet or iPad

Mobile phone

Gaming device

Kindle or E-reader

Select All

Visual History

Were you referred for an Optometric assessment due to your medical condition?

E.g. ABI, concussion or vertigo

Yes

No

Who referred you?

Please include Clinic name

When was your last visual examination?

Approximately

By whom and where?

Do you use any of the following?

Prescribed glasses

Prescription sunglasses

Non-prescription sunglasses

Contact lenses

Over the counter magnifying glasses

Non-prescription blue-light blocking glasses

Non-prescription neurological tinted glasses

Safety glasses

List any eye / vision treatment other than glasses or contact lenses:

including eye surgery & eye

Do you use eye drops?

Yes

No

Please list those those you use

Current visual symptoms

Are you also experiencing any of the following?

Sudden loss of vision

Regular headaches (not related to when using your eyes)

Floating spots in your vision

Flashing lights in your vision

Eye strain

Burning or itchy eyes

Red eyes

Distorted (wavy or wobbly) vision

Other symptoms not listed

Family history

Do you have a family history of any of the following?

Glaucoma

Macular degeneration

Cataract

Diabetes

Retinal detachment

Retinitis Pigmentosa

Strabismus (turned eye)

Amblyopia (lazy eye)

Medical history

Name of your GP

Medical Clinic

Please list any other medical or allied health professionals involved in your care?

Please list any medications you are taking (including natural supplements)

Do you have or have experienced any of the following?

Diabetes

Heart problems

Allergies / asthma

Arthritis

Cancer

Autoimmune disease

High blood pressure

Stroke

Thyroid problems

Multiple sclerosis

Plaquenil use

Methotrexate use

Type

List

Other conditions you feel are relevant

BIVSS Checklist and Survey

BIVSS Brain Injury Vision Symptom. Please fill this out even if you haven’t experienced a brain injury.

Have you ever sustained a brain injury?

Yes

No

Cause of injury

In which year did your brain injury happened?

Year or approximate years you’ve had the injury

I have had a medical diagnosis of brain injury

Yes

No

I sustained a brain injury without medical diagnosis

Yes

No

Eyesight clarity

Distance vision blurred and not clear – even with lenses

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Near vision blurred and not clear – even with lenses

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Clarity of vision changes or fluctuates during the day

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Poor night vision / can’t see well to drive at night

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Visual Comfort

Eye discomfort / sore eyes / eyestrain

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Headaches or dizziness after using eyes

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Eye fatigue / very tired after using eyes all day

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Feel "pulling" around the eyes

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Doubling

Double vision – especially when tired

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Have to close or cover one eye to see clearly

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Print moves in and out of focus when reading

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Light sensitivity

Normal indoor lighting is uncomfortable – too much glare

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Outdoor light too bright – have to use sunglasses

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Indoors fluorescent lighting is bothersome or annoying

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Dry eyes

Eyes feel "dry" and sting

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

"Stare" into space without blinking

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Have to rub the eyes a lot

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Depth perception

Clumsiness / misjudge where objects really are

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Lack of confidence walking / missing steps / stumbling

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Poor handwriting (spacing, size, legibility)

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Peripheral vision

Side vision distorted / objects move or change position

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

What looks straight ahead – isn’t always straight ahead

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Avoid crowds / can’t tolerate "visually–busy" places

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Reading

Short attention span / easily distracted when reading

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Difficulty / slowness with reading and writing

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Poor reading comprehension / can’t remember what was read

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Confusion of words / skip words during reading

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Lose place / have to use finger not to lose place when reading

Please select a number

0 – Never	1 – Seldom	2 – Occasionally	3 – Frequently	4 – Always

Consent

Communications Consent(Required)

Do you consent to us sending you occasional communications including appointment reminders, eye health information & promotions relevant to you via email, SMS or post?

Yes

No

Consent(Required)

At optometry@cooroy your privacy is our priority. Your personal information that we collect and hold about you is handled with the utmost confidentiality and security and in accordance with the Privacy Act. We may use your personal contact information to send you regarding eye health, eye care and eyewear with your consent. For more information on how we manage your privacy please contact our practice.

I agree to the Privacy Policy

Your signature

Date(Required)

Day

Month

Year

Phone

This field is for validation purposes and should be left unchanged.

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