You are in: Forms » Ophthalmic Medical History
All information is strictly confidential and utilised only for medical reference and record purposes.
Please complete as accurately as possible as your safety and wellbeing is priority to us.

Surname:
Middle Name:
Name:
Please indicate if alternate names are used for confidentiality purposes and due to high profile exclusivity. For our Records Only
Email:
Date of birth:
Postal Address:
Suburb:
Country:
Zip/Postal code:
Telephone numbers (please include international and local area codes) At least one.
Please indicate preferred number
Intl. codeLocal codenumberpreferred
work
home
mobile
fax
Emergency contact Surname:
Emergency contact Name:
Emergency contact number (please include international and local area codes)
         Intl. codeLocal codenumber
Laser Eye Surgery. At least one must be selected.
Cateracts:
Artiflex:
Lasik:
Hyperopia (Far Sighted): yes     no
Myopia (Short Sightedness): yes     no
Astigmatism: yes     no
Keratoconus (Irregular astigmatism): yes     no
Do you need reading glasses? yes     no
Blindness: yes     no
Any other eye disease? Please specify
Contact Lenses: yes     no
Type - Hard or Soft:
Strength Right Eye:
Strength Left Eye:
Previous Eye Surgery? Please specify below: yes     no
Procedure:
Current Eye Medication:
Recent Optometrist Report:
Refraction Right Eye:
Refraction Left Eye:
Stable refraction > 2 years:

General History

Date of last tests:
Allergies:
Hypertension:
Diabetes:
Malignancies:
Current Non Ophthalmic Medication:
Have you had your Cornea tested for suitability to Excimer laser surgery? yes     no
If so, please give summary of results:
Please state the recommended procedure if applicable:
We appreciate your time and thank you for completing our patient history and personal details form. Your health is of utmost concern to us. Our medical coordinator will review your information and contact you about your requirements as soon as possible.
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