• ADULT VISION QUESTIONNAIRE

  • PERSONAL DETAILS

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  • MEDICAL AND FAMILY HISTORY

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  • PRESENT SITUATION

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  • COMPUTERS

  • HOBBIES / SPORTS

  • Thank you for completing this questionnaire. The information supplied will allow for more efficient use of time.

    If you have any questions or concerns, please do not hesitate to get in touch.  Should you need to cancel the appointment please note that I respectfully request 24 hours' notice to avoid cancellation fees.

    I look forward to meeting you soon 

    Carolyn McIlvin

    Optometrist

  • CONSENTS:

    RELEASE OF INFORMATION

    IT IS OFTEN BENEFICIAL TO EXCHANGE INFORMATION AND DISCUSS YOUR EXAMINATION RESULTS WITH OTHER PROFESSIONALS INVOLVED IN YOUR CARE. PLEASE SIGN BELOW TO AUTHORISE THIS EXCHANGE OF INFORMATION.

    I give my consent to share any pertinent data from my examination with other health care providers/professionals. This authorisation shall be considered valid throughout the duration of treatment.

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  • CONSENT TO PHOTOGRAPH

    PLEASE SIGN BELOW TO AUTHORISE.

    From time to time it may be necessary and useful to photograph you in order to obtain records of eye movements, body movements and the like. The records are for the express use of the optometrist and therapist to gauge and monitor change and progress. They will not be provided to any external sources without your prior consent.

    I give my consent for me to be photographed if clinically necessary.

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  • CONSENT TO MAKE BODY CONTACT

    PLEASE SIGN BELOW TO AUTHORISE. 

    At times it may be necessary at times to guide you with prompts which may require either the optometrist or therapist to gently touching you. This will mostly be on the head, arm or leg and occasionally trunk or hips. This will usually be during therapy but may occur during the assessments. We will always check with you first.

    I give my consent for the optometrist or therapist to make body contact with me if clinically necessary.

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