Questionnaire prior to Audit eye examination

1.Full name:(Required.)
2.Age:(Required.)
3.Personal code:
4.Do you wear glasses?(Required.)
5.Do you wear contact lenses?(Required.)
6.The reason for coming to the eye examination:(Required.)
7.Have you noticed a deterioration in your eyesight? If so, please specify when:(Required.)
8.Have you had the following problems with your eyes before? (You may choose multiple answers):(Required.)
9.Have you had any eye traumas (injury/scarring)? If so, please specify, what and when it was:(Required.)
10.Do you have any medical conditions that we should be aware of? If so, please specify:(Required.)
11.Do you use any medications? If so, please specify:(Required.)
12.Has anyone in your family had an eye disease? If so, please specify:(Required.)
13.Do you have any additional comments or concerns related to the eye examination?(Required.)
14.Why did you choose KSA Vision Clinic for your eye examination?
15.How did you hear about KSA Vision Clinic?
16.Do you consent to the processing of your personal data?(Required.)