Pre-Assessment Questionnaire

1. Welcome and thank you for doing this for us

These questions usually take between 2 - 10 mins to complete, dependent on your history and/or symptoms. Since this questionnaire goes to both old and new patients, some questions will be about your previous ocular history, which if we have seen you before we may already have a record of. 
Any information you can provide is appreciated and will be noted on your record.


These questions are being asked before you come in to reduce the time we see you face to face during the COVID-19 situation. Thank you for filling in the pre-assessment questionnaire, we look forward to seeing you at your appointment.

If you need to contact us you can do so at
Tel: 01242 604654
Email: cotswoldeyecare@gmail.com
 

1. What is your name? *

*
*
 

2. What is your occupation?

 

3. Do you drive? *

 

4. Do you use display screen equipment? (Such as a computer, tablet or smartphone) If yes, what equipment do you use? *

 

5. When was your last eye examination? *

 

6. What is your reason for visiting us? *

 

7. Do you have any symptoms? *

 

8. Do you have any history of eye problems? If yes, what are they? *

 

9. Do you have any family history of ocular problems? (For example hypertension, diabetes, AMD, glaucoma, cataracts) *

 

10. Do you suffer from diabetes or high blood pressure or have anything else we need to be aware of? *

 

11. What medication are you currently taking? (Our opticians need to know this because some medications can affect your eye sight and/or eye health) *

 

12. Do you smoke?

Did you know that smokers are up to four times more likely to develop age-related macular degeneration (AMD) than non-smokers. AMD is the leading cause of sight loss in the UK. Smokers are also more likely to develop cataracts, read more at lookafteryoureyes.org/eye-care/smoking/

 

13. Do you have any allergies? *

 

14. What corrective appliance are you currently using?

 

15. Do you have any hobbies or do any sports? Prescription eyewear including swimming goggles, driving glasses, and safety spectacles are available upon request.

Check out our survey templates or create your own.