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Children’s Vision
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New Patient – Adult Questionnaire
New Patient - Adult Welcome to Total Optical
Welcome to Total Optical
Thankyou for choosing our practice. Please provide the following information:
Patient Details
Name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Title
First
Last
Date of birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Occupation
(Required)
Mobile Phone
(Required)
Work Phone
Home Phone
Home Address
(Required)
Street Address
Address Line 2
City
State
Post Code
Postal Address - if different to Home Address
Mailing Address Line 1
Mailing Address Line 2
City
State
Post Code
Email
(Required)
Enter Email
Confirm Email
What is your preferred method of contact?
Mobile
Home Phone
Work Phone
Email
GP's Name
GP's Practice/Address
(Required)
Are you covered by a private Health Fund?
(Required)
Yes
No
If yes, Which Health Fund?
When was your last eye exam?
(Required)
Lifestyle Considerations
Do you have any hobbies, sports or special interests?
(Required)
Yes
No
If yes, please specify
Do you require safety glasses for occupational or sporting activities?
(Required)
Yes
No
If yes, please specify
Do you work on a computer for extended periods?
(Required)
Yes
No
Do you spend a lot of time outdoors?
(Required)
Yes
No
Do you wear presciption sunglasses?
(Required)
Yes
No
Are you currently wearing spectacles?
(Required)
Yes
No
If yes, approximatley how old are they?
Are you currently wearing contact lenses?
(Required)
Yes
No
If no, would you like to know more about them?
Yes
No
Medical History
Please indicate if you or a member of your family have ever experienced any of the following:
(Required)
Eye Surgery
Eye Injury
High Cholesterol
Lazy Eye
Heart Disease
High Blood Pressure
Glaucoma
Allergies
Stroke
Cataracts
Diabetes
Macular Degeneration
Other
None
If other, please specify
Are there any particular concerns or questions you have about your vision or eye health?
(Required)
Yes
No
If yes, please specify
How did you hear about our practice?
Untitled
Friend or relative
Previous patient
Health Care Practitioner
Yellow Pages
Untitled
Location
Facebook
Google
Other
Privacy Statement
Are you happy for us to send you eye health, eye care and eyewear information electronically (for example by SMS or email)?
(Required)
Yes
No
Are you happy for us to provide your personal contact information to our product suppliers, partners and service providers to assist us in sending you this information (and for no other purpose)?
(Required)
Yes
No
Consent
I agree to the privacy policy.
Our practice respects your privacy and will comply with the Privacy Act and the National Privacy Principles when handling your personal
information. We use your personal information to help us provide services to you and with your permission, to send you information regarding
eye health, eye care and eyewear. If you do not provide information requested in this form we may be unable to provide services to you, or our
ability to do so may be impaired. You can access most personal information that we hold about you. Please contact us if you would like to know
more about how we handle your personal information.
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