Before your consultation for an assessment please complete and email us this short Pre-Visit Questionnaire.

Contact Lenses should never be supplied without a detailed and extensive examination of the eyes carried out by a dedicated Contact Lens Specialist – not all Opticians are legally qualified to fit or supply contacts.

Therefore before we fit you with Contacts it is vital that we gain a full history of your eyes, your general health as well as your visual needs both at work and at play – all have a bearing on the final choice of lens design we advise most suitable for your individual clinical needs.

Please complete this form and email it to us before your initial Contact Lens Assessment to assist us us compiling your record card. When most new patients visit they are surprised at the array of specialist equipment we utilise to gain the fullest details of your eyes and their shape etc.

You’ ll see what we mean if you click here to see the basic equipment in our instrument room!

In a SPECIALIST practice like ours you should allow at least 2 hours for your initial consultation.

Fields marked * are mandatory

Personal information

ID *   If you have made an appointment insert ID given otherwise insert 1234

(dd/mm/yyyy)

Contact lens history

Approximately how long ago was your last eye test: years months ago.

Yes
No

Yes
No
N/a

Soft Plastic
Rigid Gas Permeable
Soft Sleep-In Lenses
Rigid Sleep-In Lenses
Other

Daily Disposable
2 Weekly Disposable
Monthly Replacement
3 Weekly Disposable
Yearly Disposable
Worn Longer

Health history

It is dangerous to fit lenses without full medical and ocular details. Very few conditions preclude fitting. Many suggest a specific lens material or type of fitting.

To reassure you. Lots of 'ticks' do not mean you are unsuitable. A final decision is only possible after a tolerance trial.

Please place a tick in the appropriate box should you at present, or in the past, have suffered with any of the following conditions. Should there be any other points which you think relevant, please add these at the bottom under "any other details".

Conjunctivitis
Styes
Cysts
Lid Conditions
Squint, Turn or Cast
Nystagmus
Injuries to Eye or Lid
Regular Headaches
Migraine
Allergies
Hayfever
Catarrh
Epilepsy
Skin Rashes
Thyroid Conditions
Kidney Conditions
High Blood Pressure
Heart Condition
Arthritis
Depression
Sinus
Diabetes
More difficulty in sunlight than most people
More difficulty in smoky conditions than most
Have you had any form of eye surgery or eye disease
Do you have a regular sleep pattern
Do you sleep at least six hours per night
Apart from routine fillings do you have any other problems with your teeth
Do you take any pills or other drugs, prescribed or not, on a regular basis including the birth control pill, HRT, Diuretics, etc.
Are you at present undergoing any medical treatment
Have you in the past three months had any major changes to your body, e.g. pregnancy, childbirth, operation
Do you suffer with dry eyes

Dry Eye Test

Not sure if you have dry eyes? Try this simple test.

Blink Twice and then slowly count the numbers shown below.


1 2 3 4 5
6 7 8 9 10
11 12 13 14 15

If you can't get to Ten without needing to blink again
then you may have Dry Eyes.

Further information

Do you partake in:

Yes
No

Yes
No

Yes
No

Constantly
Occasionally
Never

Yes
No

All Day
Occasionally
Never

Overnight Vision Correction - Ortho-K

If you are short sighted and not above -8.0 dioptres OVC lenses generally offer more advantages than any other form of eye correction - especially Laser Surgery. Click here to discover OVC.

Further information

Yes
No

Recommendation
Web Site
Opticians Suggestion
Seeing the Practice
Advert
Other

If recommended to us by a friend please give us their name so we may thank them.

Recommend a friend

If you know anyone who's been told they're unsuitable or who've tried and failed we're certain we can help them! Please give us some contact details so we can talk to them -- if you can't please DO TELL THEM TO LOOK AT THIS WEB SITE.

Subject to Suitability I am Interested in - (Details Under 'Lens Types')

Flexible Oxygen Permeable
Soft Sleep-In
Soft Daily Wear Monthly
Soft Daily Disposables
Hybrid Lenses
Overnight Vision Correction
Will be Advised

I would Like To Wear Contacts

Everyday

Approx Days A Week

Your Spectacle Correction

under 2 years
over 2 years

If over 2 years the law requires you have a Sight Test before you are fitted with Contacts - this will be part of your initial consultation.

If under two years please bring your latest glasses with you when you attend.

If you have your latest prescription details please write it below:

Right
 SPHCYLAXISReading
Addition
Left

CONFIDENTIALITY
All personal and clinical information is treated in strict confidence. No detail of your case history will be given to anyone except with your written permission.

Please click on the following button to send this information to our staff.