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Our South Brisbane location has moved. We are now located at 87 Ipswich Rd, Woolloongabba QLD 4102

Dr Geoffrey Ryan

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Home
Dr Ryan Treats…
About
Blog
Patient Info
Contact

(07) 3239 5000

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Home
Dr Ryan Treats…
About
Blog
Patient Info
Contact

Home
Dr Ryan Treats…
About
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:

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:

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

Email

Date of your appointment (if known)

MM slash DD slash YYYY

3012570713

Locations

Woolloongabba

87 Ipswich Rd, Woolloongabba QLD 4102

Treatments

Cataracts
Glaucoma
Keratoconus

Pterygium
Corneal Conditions

Contact

(07) 3239 5000
Enquiry Form
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