Questionnaire prior to Audit eye examination
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1.
Full name:
(Required.)
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2.
Age:
(Required.)
3.
Personal code:
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4.
Do you wear glasses?
(Required.)
Yes, minus glasses
Yes, plus glasses
Yes, multifocal lenses
No
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5.
Do you wear contact lenses?
(Required.)
Yes
No
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6.
The reason for coming to the eye examination:
(Required.)
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7.
Have you noticed a deterioration in your eyesight? If so, please specify when:
(Required.)
No
Yes
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8.
Have you had the following problems with your eyes before? (You may choose multiple answers):
(Required.)
Keratoconus
Retinal disorder
Claucoma
Corneal disorder
Cataract
Ambliopia
None
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9.
Have you had any eye traumas (injury/scarring)? If so, please specify, what and when it was:
(Required.)
No
Yes
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10.
Do you have any medical conditions that we should be aware of? If so, please specify:
(Required.)
No
Yes
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11.
Do you use any medications? If so, please specify:
(Required.)
No
Yes
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12.
Has anyone in your family had an eye disease? If so, please specify:
(Required.)
No
Yes
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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?
I did my own research and searched online
I received a recommendation from a friend, acquaintance, or family member
I saw a post or advertisement on social media (Facebook, Instagram)
I saw information through another channel (e.g., a banner on Delfi, an article in Postimees, a video on TikTok, an advertisement in a gym, etc. Please specify):
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16.
Do you consent to the processing of your personal data?
(Required.)
I agree to the terms of personal data protection.