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Have you had any eye advice given to you by a GP or other health professional *

Yes

No

What advice was given? *

Have you ever exprienced any of the following

Eye pain *

Yes

No

Which eyes give you eye pain? *

Left eye

Right eye

Discomfort with bright light *

Yes

No

Which eyes give you discomfort? *

Left eye

Right eye

Recent Trauma to the eyes *

Yes

No

Which eyes suffered trauma? *

Left eye

Right eye

Distortion of your vision *

Yes

No

Which eyes suffer from distortiion? *

Left eye

Right eye

Recent Floaters *

Yes

No

Which eyes do you get floaters in? *

Left eye

Right eye

Red Eyes *

Yes

No

Which eyes suffer from red eye? *

Left eye

Right eye

Sudden changes in vision *

Yes

No

Please describe sudden changes *

Do you have any mediacal conditions or prescriptions? *

Yes

No

Please describle the issues briefly *

Headaches *

Yes

No

Shadows in vision *

Yes

No

Which eyes were affected? *

Left eye

Right eye

Have you ever visited hospital for your eyes at any time *

Yes

No

Have you ever been told you have had any of the following:

cateracts *

Yes

No

Which eyes were affected with cateracts? *

Left eye

Right eye

Wear & tear at the back of your eyes *

Yes

No

Wear & tear at the back of your eyes eye *

Left eye

Right eye

Macular Degeneration *

Yes

No

Macular Degeneration eye *

Left eye

Right eye

Glaucoma/raised pressure in your eyes *

Yes

No

Which eyes were affected with glaucoma? *

Left eye

Right eye

Any other eye conditions *

Yes

No

Any other eye conditions note

Any family members had eye conditions *

Yes

No

PLease describe family eye conditions *

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