Optometry Practice

69 Hampden Road
Nedlands WA

(08) 9386 3620

Make an appointment

Eyesight can be optimized by wearing contact lenses or spectacles. Ezekiel Eyes provides a range of options for both of these.

Ring 9386 3620 and make a time to see an optometrist

Write it down in your diary

So that you are not waiting when you arrive please fill in this patient history form.

Patient Information

In preparing for your first visit to Ezekiel Eyes, we require some information about you. Please provide the following details:

Name

Surname

Given Names

Address

Street, Suburb

Postcode

Sex

Male Female

Date of Birth

Phone

Home

Work

Mobile

Occupation

Have you had your eyes tested in the past two years?

Optometrist

Date

General Practitioner

Name

Address

Concessions

Pensioner Card Veteran’s Affairs Card Health Care Card

Who can we thank for recommending you to our practice?

Name

Reason(s) for the appointment

General eye health Spectacles Contact lenses

Eye Information

Currently wearing

Hard contact lenses Soft contact lenses None

Have you ever had drops prescribed or other treatment for dry eyes?

Yes Uncertain No

Do you experience any of the following eye symptoms?

Soreness Scratchiness Dryness Grittiness Burning

How often do your eyes have these symptoms?

Constantly Often Sometimes Never

Are your eyes unusually sensitive to cigarette smoke, smog, air-conditioning and/or central heating?

Yes Sometimes No

Do your eyes become very red and irritated when swimming?

Don't Swim Yes Sometimes No

Are your eyes dry and irritated the day after drinking alcohol?

Don't Drink Yes Sometimes No

Do you take any of the following?

Do you suffer from arthritis?

Yes Uncertain No

Do you experience dryness of the nose, mouth, throat, chest or vagina?

Constantly Often Sometimes Never

Do you suffer from thyroid abnormality?

Yes Uncertain No

Are you known to sleep with your eyes partly open?

Yes Sometimes No

Do you have eye irritation as you wake from sleep?

Yes Sometimes No

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