Welcome to Our Practice - Eyecare Plus Newton Village
Saturday 28th of January 2012
This questionnaire will provide information needed to complete your visual health record. Please answer all questions as completely as possible.
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The Basics
Salutation:
First Name:
Surname:
Date of Birth:
Address:
Suburb / Town:
State:
Postcode:

Concessions, Medicare & Private Health Insurance
We only charge the Scheduled and Recommended Fees, with consultations DIRECT BILLED to Medicare. Do you have any other entitlements that may cover some of our services?
Type:
Reference #:		 Pension Health Care DVA Seniors
Medicare #: Ref:
Expiry
Do you have private health insurance?
Yes   No
Fund Name:
Ref #:
Contact Info
Phone: Home
Work
Mobile
Email:

General Info
Occupation:
Hobbies & Sports:
Main reason for your visit:
Do you currently wear spectacles or contact lenses?
Yes   No
Would you like to update your spectacle frames?
Yes   No
Are you happy with your current glasses or contact lenses?
Yes   No
Do you suffer from red eyes?
Yes   No
Do you suffer from itchy eyes?
Yes   No
Do you suffer from headaches?
Yes   No
Whom may we thank for referring you to our practice?
 
Medical History Please check all that apply.
 
Yes
Yes
Yes Yes
Yes Yes
Have you ever had:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes 		Are you taking medication for:
  • Other:
Date of your last eye exam?


Who performed it?
 Yes
Yes
Yes
Yes
required

Thank you for completing the form. This will help us care for your eyes.