Questionnaire prior to Flow 2.0 eye procedure
Personal data sheet
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1.
Full name:
(Required.)
*
2.
Sex:
(Required.)
Female
Male
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3.
Age:
(Required.)
*
4.
Personal code:
(Required.)
*
5.
Your profession:
(Required.)
*
6.
Hobbies:
(Required.)
*
7.
Do you wear contact lenses?
(Required.)
No
Yes
*
8.
How frequently do you wear contact lenses?
(Required.)
Daily
A few days a week
Only during sports
Only during special events
Seldom
Never
*
9.
Have you ever experienced any of the following problems with your eyes? (You may choose multiple answers)
(Required.)
Keratoconus
Glaucoma
Retinal disorder
Corneal disorder
Cataract
Amblyopia
None of the above
*
10.
Have you had any eye traumas (injury/scarring)? If so, please specify, what and when it was:
(Required.)
No
Yes
*
11.
Have you ever experienced any of the following symptoms in your eyes? (You may choose multiple answers)
(Required.)
Spontaneous "lightning" sensation
Spots or "grains of dust" in your vision
Temporary or permanent malfunction of colour perception
Shadow or visual hindrance in field of vision
Difficulty seeing in the dark/dim light
Eyes tire quickly while reading
Dryness in the eyes
Halos around lights in the dark
None of the above
*
12.
Have any of your close relatives had a serious eye condition?
(Required.)
No
Yes
*
13.
Do you have any conditions or problems we should be aware of? If so, please specify:
(Required.)
No
Yes
*
14.
Have you received any vaccinations during the past two years? If so, which vaccines did you receive?
(Required.)
No
Yes
*
15.
Have you undergone any surgeries in the past year? If so, please specify:
(Required.)
No
Yes
*
16.
Have you ever had any of the following? (You may choose multiple answers)
(Required.)
Blood transfusion
Corneal herpes
Diabetes
Epilepsy
Hepatitis B
Hepatitis C
Autoimmune disorder (rheumatoidarthritis, inflammatoryintestinal disorder, lupus)
Contact with AIDS
HIV
Cheloidal scars
Pacemaker
None of the above
*
17.
Do you have any allergies or hypersensitivity to any medications? If so, please specify:
(Required.)
No
Yes
*
18.
Do you use any of the following medications? (You may choose multiple answers)
(Required.)
Antibiotics
Anticoagulants
Blood pressure medications
Cardiac medications
Nitroglycerine
Tranquillisers
Anti-anxiety medications
Sleeping pills
Aspirin
Analgesics
Antidepressants
Steroids
Insulin
Cholesterol medications
Acne medicaments
No
*
19.
Do you confirm the accuracy of the above information and consent to the processing of your personal data?
(Required.)
I confirm the accuracy of the above information and
agree to the terms of personal data protection
.