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Dr Geoffrey Ryan
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Dr Ryan Treats…
Cataracts
Pterygium
Glaucoma
Keratoconus
Corneal Conditions
Refractive Surgery
About
About the Practice
Get to Know your doctor
Locations & Facilities
Blog
Patient Info
Contact
Home
Dr Ryan Treats…
Cataracts
Pterygium
Glaucoma
Keratoconus
Corneal Conditions
Refractive Surgery
About
About the Practice
Get to Know your doctor
Locations & Facilities
Blog
Patient Info
Contact
(07) 3239 5000
Book Appointment
Patient Info
Home
Dr Ryan Treats…
Cataracts
Pterygium
Glaucoma
Keratoconus
Corneal Conditions
Refractive Surgery
About
About the Practice
Get to Know your doctor
Locations & Facilities
Blog
Patient Info
Contact
Home
Dr Ryan Treats…
Cataracts
Pterygium
Glaucoma
Keratoconus
Corneal Conditions
Refractive Surgery
About
About the Practice
Get to Know your doctor
Locations & Facilities
Blog
Patient Info
Contact
Refractive Surgery Questionnaire
Refractive surgery questionnaire
Patient medical history
1. General Health: please tick if you have the following:
Hypertension
Diabetes
Heart Disease
Asthma
Rheumatoid Arthritis
Hay Fever
Eczema
Neurosurgery
Currently Pregnant
Currently Breastfeeding
Please list any other medical conditions:
2. Please list any allergies:
3. Current Medications:
4. Ocular History - Please indicate if have been diagnosed or suffer from:
Herpes Simplex/ Cold sores affecting the eye
Shingles involving the eye
Previous eye injuries
Corneal Erosions
Allergic Conjunctivitis
I often see Haloes in my vision
I suffer from Glare
I have issues driving at night due to my vision
Dry Eye
Red Eyes
Iritis/ Uveitis/ Inflammation of the eyes
5. Family History - Please indicate if anyone in your family has a history of:
Glaucoma
Cataract
Myopia (short sighted)
Retinal Detachment
Keratoconus
Corneal graft surgery
6. Do you wear contact lenses?
Yes (please provide additional information below)
No
6a. Additional information (Contact Lenses) - Please select one option:
I wear soft contact lenses.
I wear rigid (hard) contact lenses.
I use Ortho K lenses.
I am not sure what type I wear.
6b. Important Contact Lens info: Please remove your soft contact lens for at least two weeks prior to your appointment at the clinic. Rigid contact lenses must be removed at least 4 weeks prior. Please select from the following:
I understand and will follow this advice.
I can not function without contact lenses and need advice on what to do.
I use Ortho K - please advise me what to do.
7. What is your occupation?
8. Interests/hobbies - tick each that applies:
Contact sports eg boxing, martial arts, rugby
Non contact sport
Reading
Computer work
Art
Music
8a. Other interests/hobbies not listed:
9. Please tick if you hold the following licenses?
Commercial License
Heavy Vehicle License
Pilot License
10. Why do you want refractive surgery?
11. Do you have any specific concerns that you need addressed at your consultation?
Name
First
Last
Phone
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Date of your appointment (if known)
MM slash DD slash YYYY
