R.N.Roberts Optometrists in Cardiff - Pre-Examination Questionnaire

Pre-Examination Questionnaire

(No need to fill in Questionnaire for Spectacle Repair, Spectacle Adjustment or Spectacle Collection Appointments)

Title(*)

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First Name(*)

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Surname(*)

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Gender/Sex(*)

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DOB(*)

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Contact Details

Telephone(*)

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Mobile(*)

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Email(*)

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Address(*)

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GP Surgery and Doctor(*)

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NI Number(*)

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NHS Number

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Stating your ethnicity helps to determine your risk of eye disease. Please choose one section and tick the box that best describes your ethnic background:

State Ethnicity(*)

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School/College/University Name and Address if 18 years old or under

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Are you or your Partner in receipt of any benefit that entitle you to help with the cost of spectacles? If so, which benefit?

Person getting the benefit if not the patient:

Full Name

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DOB

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NI Number

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I confirm that the following details are correct to the best of my knowledge(*)

YesNo Invalid Input

We have Disabled access to the practice along with a wheelchair friendly consulting room. Please advise if you require either of these services

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What has prompted you to make an appointment

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Are you currently or ever have been under the care of the hospital relating to your eyes(*)

YESNO Invalid Input

Do you or an immediate family member have any condition that may affect your sight / Eyes (*)

YESNO Invalid Input

If yes to either of the above please provide details(*)

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Do you have any new ;

Flashing Lights Or Floaters(*)

YESNO Invalid Input

Headaches(*)

YESNO Invalid Input

Double Vision(*)

YESNO Invalid Input

Dry Or Watery Or Uncomfortable Eyes(*)

YESNO Invalid Input

Do you currently wear Contact Lenses? (*)

YESNO Invalid Input

Please give the names of any general health conditions you have and any prescribed medication

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Do you have any known allergies(*)

YESNO Invalid Input

If yes please provide detail(*)

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What is your occupation(*)

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Do you have any specific sports or hobbies you may require spectacles or contact lenses for(*)

YESNO Invalid Input

If yes please specify(*)

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Do you ;

Smoke(*)

YESNO Invalid Input

Drive(*)

YESNO Invalid Input

We offer an OCT Scan / Retinal Photography as an additional part of your eye examination. Do you consent to us carrying this out if your Optometrist considers it necessary? (*)

YESNO Invalid Input

Please note: Additional scan will cost £35

Please see our OCT scan / Retinal Photography service page for more info

Signed(*)

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Date(*)

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