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Steel & Varley Pre-test Patient Questionnaire
First name
*
Last name
*
Email (if you have one)
Birthday
*
Day
Month
Year
GP Surgery
Reason for Visit (tick any that apply)...
Eye health concern
Change in vision
Broken glasses
Want new glasses
Responding to recall
Interested in contact lenses
Other
Other
What glasses do you currently wear?
Varifocals
Bifocals
Single Vision Distance
Single Vision Reading or Computer
I don't wear glasses
Tell us about your glasses wear (if applicable). Do you...
Get any sight problems at night
Get light senisitivity
Have a spare pair
Have problems with sun or refelctions off surfaces, such as a wet road
Have problems with your glasses lipping down your nose
Fancy a new pair/change of style
Audiology. Have you noticed any problems with your hearing?
Yes
No
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