Pre-Assessment Questionnaire

1. Welcome and thankyou for doing this for us

These questions usually take about 5 - 10 mins to complete.
If you want to go into more detail and take longer you are more than welcome!


These questions are being asked before you come in to reduce the time we see you face to face during the COVID-19 situation. Thanyou 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? *

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2. Do you drive? *

 

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

 

4. What is your occupation?

 

5. When was your last eye examination? *

 

6. What is your reason for visiting us? *

 

7. Have you got any symptoms? *

 

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

 

9. What medication are you currently taking?

 

10. Do you have any history of eye problems, if yes what are they? (For example dry eyes, AMD, blepharitis, glaucoma, cataracts, retinal detachment and/or surgery) *

 

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

 

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 sports?

Check out our survey templates or create your own.