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Eye Examination checklist

In order that you get the most from your eye examination, you may like to complete this simple checklist.  This will help the optometrist determine your precise requirements.  Please print it out and complete it at your leisure and bring it together with your prescribed medication list and most current spectacle prescription to the appointment.

Is this your first examination?

YES/NO   

Do you take regular mediation?

YES/NO   

Do you drive?

YES/NO   

Can you read TV subtitles/ teletext?

YES/NO   

Do you currently wear glasses?

YES/NO   

If yes please bring them with you

Are your spectacles comfy and lightweight?

YES/NO   

Do you have a back up pair in case of loss or damage?

YES/NO   

Do you wear contact lenses?

YES/NO   

If yes please bring them with you and your specs and any lens / solution packaging you have.

Do you have any family history of eye problems?

YES/NO   

If you are a new patient to the practice what was the reason for choosing us?

Dunelm - RETRO304  MODEL2 Dunelm - RETRO304 MODEL2 Charles Lea  Opticians Ltd. Telephone: (0115) 960 6526 Name & Registered Office:  CHARLES LEA OPTICIANS LIMITED, 27 CASTLEGATE,  NEWARK ON TRENT, NOTTINGHAMSHIRE, ENGLAND, NG24 1BA.  Company No. 07202587