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Group 4
Group 4
Group 4
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Refractive Eye Questionare
We offer comprehensive diagnosis and management of all eye conditions using state-of-the-art diagnostic equipment. Our aim is to deliver the highest quality care for our patients and achieve excellent clinical results.
Refractive Eye Questionare
Patient Details
Title
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Mr
Mrs
Miss
Ms
Mstr
Capt
Prof
Dr
First Name
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Surname
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Date Of Birthday
Occupation
I normally Wear (please tick all appropriate)
Glasses:
Distance
Reading
Multifocals
Contact Lenses:
Soft
Hard
Last Worn
How long have you worn glasses / contact lenses?
Are you contact lens intolerant?
Do you have trouble wearing glasses?
Are you or have you recently been pregnant or breastfeeding?
Hobbies / sporting activities?
What prompted your interest in laser vision correction?
Conditions
Please list any current health conditions
Please list any current medications
Do you or your family have any history of eye disease?
Dry Eyes
Cataract
Glaucoma
Macular Degeneration
Keratoconus or corneal disease
Other
Please list any allergies
Do you use any eye drops?
How Often?
Where did you hear about CSES?
GP
Optometrist
Word Of Mouth
Google
Social Media
Other
What questions or concerns do you have about laser surgery?
If you are human, leave this field blank.
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