Sight Test Questionnaire

xooptix

First Name *

Last Name *

Email *

Phone *

As of today, are you under the age of 19 OR over 64 years old? *

Yes

Do you have recent head or eye injury? *

Yes

Are you diagnosed with diabetes and on medication? *

Yes

Are you diagnosed with glaucoma? *

Yes

Do you have double vision? (This is different from having astigmatism/cylinder in your corrective lenses) *

Yes

Do you wear corrective lenses containing prism? *

Yes

Are you seeing sudden flashes of light

Eye flashes appear just as their name suggests — they are bright (often arc-shaped or jagged) flashes of light, which tend to appear more frequently in your peripheral vision. Eye flashes could signal you are at risk of a retinal detachment, which is a medical emergency. If you suddenly see flashes of light and a large number of floaters, see an eye doctor immediately to rule out the beginning of a detached retina. *

Yes

Do you have high blood pressure? *

Yes

Do you have macular degeneration? *

Yes

Do you have retinal detachment? *

Yes

Are you suddenly noticing a large number of new floaters, or floaters along with flashes or a dark shadow or a ‘curtain’ in your vision?

Eye 'floaters' appear as small shadowy spots, clumps, and irregular linear and fuzzball-like shapes (like the “pilling” of the fibers of a sweater) that drift slowly across your field of view — which makes them appear as though they are floating in front of your eyes. A few floaters here and there are very common and usually are not a symptom that anything is seriously wrong with your eyes (especially if you notice only a few floaters and they aren’t accompanied by flashes of light). *

Yes

Do you have blind spots in your field of view?

(This is different from being near/far-sighted or needing reading glasses) *

Yes

Do you/Have you had any other eye diseases or eye surgeries? *

Yes

Which language do you prefer? (Check all that applies) *

English

Mandarin

Cantonese

By giving us your contact info, you agree to receive phone calls, text, WhatsApp messages, emails, and or other forms of communication from us regarding your appointment and/or order. *

I Agree

Reason for getting the sight test? *

Date of last eye exam

PLEASE NOTE:

A sight test (refraction) is performed by an optician to determine your prescription. *

I Agree

A sight test is NOT a medical eye examination and will NOT determine the presence of eye disease. *

I Agree

In compliance with COVID protocols, please specify how many people will accompany you to the appointment (if any)

I have read and understood all the information contained in this notice. I authorize the release of the information pertaining to this form.

By receiving services and/or products supplied by XO OPTIX Vision Care, I have agreed to XO’s general policies, which is made available to me upon request and on the website (www.xooptix.ca).

I understand that all services and prescription sales are final and non-refundable.

*Please hand-sign in the space below *

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Please contact me for giveaways, promotions, and events. (You may unsubscribe at any time)

Yes

I'd like to receive helpful info related to the health of my eyes, eyewear styles, brand highlights, and vision care tips. (You may unsubscribe at any time)

Yes

Thank you for taking the time to complete this questionnaire!

You can now choose a time and date of your sight test by clicking the SUBMIT button.