Pre-Appointment Questionaire


Thankyou for filling in this Pre-Appointment Questionaire to save you time at your appointment. This will give us more time to spend on your consultation with the Optometrist.

Welcome to High Sight Optometry
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Home Phone*
Business Phone
E-mail Address*
Mobile phone
Date of Birth*
My Occupation
I heard about High Sight Optometry through:*
Do you have health fund extras?*
Do you have hobbies requiring good close vision?*
No
Reading
Needlework
Wood/metalwork
Gardening
Other
Which sports do you regularly participate in?*
contact sports - Netball, basketball, football
Fast ball sports - Squash, tennis, cricket, baseball
Glare - Skiing/Snowboarding
Water -Sailing, swimming, fishing, diving
Aerobic - gym, dance
Other
None
Have you or your family had any of the following?*
Eye Injury
Eye Surgery
Glaucoma
Macular Degeneration
High Blood Pressure
Asthma
Allergies
Smoker
Other
None
How long since your last Eye Test?*
I currently use:*
I am interested in trying Contact Lenses:*
I spend a lot of time on a computer:
I spend a lot of time outdoors:

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