Patient form

Filling in this form is voluntary, however it will help us prepare for your visit.
If you are unable to answer some of the questions you may leave them blank.

1. Full name:

2. What is your visual acuity currently?

Right eye Left eye

3. When did you receive your first spectacles?

4. When were you last issued spectacles? (If possible please bring your last prescription and/or spectacles.)

5. When was your last visit to an eye care physician?

6. Have you or are you currently experiencing the following:

Blurry vision

Distorted vision

Pain or pricks in your eyes

Light flashes

Hovering blurry areas in your vision

A static patch or shadow in your vision

Eye infections

Any trauma or injury to your eyes

Glaucoma

Any foreign objects in your eyes

Any other problems not listed here

7. Have your eyes been operated on?

8. Have you used any eye drops or ointments?

9. Please try to describe the main problem with your eyes currently.