New Patient Form - TK&S Optometrists

- First Name*
- Last Name*
- Date of Birth*
- Patient ID (TKS Staff Only)
- Eye History
  (Patching as a child/Accidents/Hospital Visit. Have you previously tried contact lenses, what have you tried/when) Lipiflow /IPL
- Medications
  (List all, prescribed and over the counter e.g Contraceptive Pill or Anti-histamines)
- Allergies to Medicines
- Eye Prescriptions
  (Any current eye drops being used or tablets being taken to help eye conditions)
- Eye Family History
  Parents/Siblings/Children - any conditions such as Glaucoma, Macula Degeneration, Blindness, Myopia (short sighted), Strabismus (‘squint/caste’) Keratoconus
- Eye Operations
  (Such as cataract surgery, laser surgery, retinal or lid surgery)
- Social History
  Do you smoke or drink? - How much/Often? Hobbies? Sports?
- Medical History
  Do you or a close family member suffer from general (systemic) health conditions such as blood pressure, cholesterol, thyroid. For kids, were they Full Term and healthy baby (no long spell in hospital)
- Contact Lens History