Questionnaire for Adults new to our clinic

We ask you to take a few moments to complete this form. The purpose of collecting this information is to assist us in providing you with the highest quality eye-care. All information will be treated in the strictest confidence in accordance with the Privacy Act. As you complete this history questionnaire we hope that you will recognize the thoroughness with which your vision will be considered.

Visual History

Do you experience any of the following?

Please check any of these eye conditions that apply to you or run in your family

Health History

Please check any of these health conditions that apply to you or run in your family

Digital Retinal Imaging and OCT scanning is likely to be recommended in which case there will be a fee of $75 ($65 for pension card holders and health care card holders)