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.

If you prefer you can download the form and bring it with you to your appointment. Download form here

Welcome to High Sight Optometry

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Home Phone*
Home Phone*

Business Phone

E-mail Address*
E-mail Address*

Mobile phone

Date of Birth*
Date of Birth*

My Occupation

I heard about High Sight Optometry through:*
I heard about High Sight Optometry through:*

Do you have health fund extras?*
Do you have health fund extras?*

Do you have hobbies requiring good close vision?*
Do you have hobbies requiring good close vision?*

	No
	Reading
	Needlework
	Wood/metalwork
	Gardening
	Other

Which sports do you regularly participate in?*
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?*
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?*
How long since your last Eye Test?*

I currently use:*
I currently use:*

I am interested in trying Contact Lenses:*
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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The information presented here is of a general nature and is not intended to replace the personal advice of your Eye Care Practitioner. Please seek professional help for specific concerns.

Pre-Appointment Questionaire

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