Questionnaire about your eyes Pre-Consultation Questionnaire Patient’s name :(Required)Date of Birth :(Required) DD slash MM slash YYYY AgeNationality(Required)AfghansAlbaniansAlgeriansAmericansAndorransAngolansAntiguans and BarbudansArgentinesArmeniansArubansAustraliansAustriansAzerbaijanisBahamiansBahrainisBangladeshisBarbadiansBasquesBelarusiansBelgiansBelizeansBenineseBermudiansBhutaneseBoliviansBosniaksBosnians and HerzegoviniansBotswanaBraziliansBretonsBritishBritish Virgin IslandersBruneiansBulgariansMacedonian BulgariansBurkinabésBurmeseBurundiansCambodiansCamerooniansCanadiansCatalansCape VerdeansList of CaymaniansChaldeansChadiansChileansChineseColombiansComoriansCongolese (DRC)Congolese (RotC)Costa RicansCroatsCubansCypriotsCzechsDanesGreenlandersDjiboutiansDominicans (Commonwealth)Dominicans (Republic)DutchEast TimoreseEcuadoriansEgyptiansEmiratisEnglishEquatoguineansEritreansEstoniansEthiopiansFalkland IslandersFaroeseFijiansFinnsFinnish SwedishFilipinosFrench citizensGaboneseGambiansGeorgiansGermansBaltic GermansGhanaiansGibraltariansGreeksGreek MacedoniansGrenadiansGuatemalansGuianese (French)GuineansGuinea-Bissau nationalsGuyaneseHaitiansHonduransHong KongersHungariansIcelandersI-KiribatiIndiansIndonesiansIraniansIraqisIrishIsraelisItaliansIvoiriansJamaicansJapaneseJordaniansKazakhsKenyansKosovarsKuwaitisKyrgyzsLaoLatviansLebaneseLiberiansLibyansLiechtensteinersLithuaniansLuxembourgersMacaoMacedoniansMalagasyMalawiansMalaysiansMaldiviansMaliansMalteseManxMarshalleseMauritaniansMauritiansMexicansMicronesiansMoldovansMonégasqueMongoliansMontenegrinsMoroccansMozambicansNamibiansNauruansNepaleseNew ZealandersNicaraguansNigeriensNigeriansNorwegiansOmaniPakistanisPalauansPalestiniansPanamaniansPapua New GuineansParaguayansPeruviansPolesPortuguesePuerto RicansQatariQuebecersRéunionnaisRomaniansRussiansBaltic RussiansRwandansSaint Kitts and NevisSaint LuciansSalvadoransSammarineseSamoansSão Tomé and PríncipeSaudisScotsSenegaleseSerbsSeychelloisSierra LeoneansSingaporeansSlovaksSlovenesSolomon IslandersSomalisSomalilandersSothoSouth AfricansSpaniardsSri LankansSudaneseSurinameseSwaziSwedesSwissSyriacsSyriansTaiwaneseTamilsTajikTanzaniansThaisTibetansTobagoniansTogoleseTongansTrinidadiansTunisiansTurksTuvaluansUgandansUkrainiansUruguayansUzbeksVanuatuansVenezuelansVietnameseVincentiansWelshYemenisZambiansZimbabweansReachable Number(Required)Country code :Contact E-mail(Required) What is your residential address? Phuket Other part of Thailand Other Countries Other part of Thailand(Required)กรุงเทพมหานครสมุทรปราการนนทบุรีปทุมธานีพระนครศรีอยุธยาอ่างทองลพบุรีสิงห์บุรีชัยนาทสระบุรีชลบุรีระยองจันทบุรีตราดฉะเชิงเทราปราจีนบุรีนครนายกสระแก้วนครราชสีมาบุรีรัมย์สุรินทร์ศรีสะเกษอุบลราชธานียโสธรชัยภูมิอำนาจเจริญหนองบัวลำภูขอนแก่นอุดรธานีเลยหนองคายมหาสารคามร้อยเอ็ดกาฬสินธุ์สกลนครนครพนมมุกดาหารเชียงใหม่ลำพูนลำปางอุตรดิตถ์แพร่น่านพะเยาเชียงรายแม่ฮ่องสอนนครสวรรค์อุทัยธานีกำแพงเพชรตากสุโขทัยพิษณุโลกพิจิตรเพชรบูรณ์ราชบุรีกาญจนบุรีสุพรรณบุรีนครปฐมสมุทรสาครสมุทรสงครามเพชรบุรีประจวบคีรีขันธ์นครศรีธรรมราชกระบี่พังงาภูเก็ตสุราษฎร์ธานีระนองชุมพรสงขลาสตูลตรังพัทลุงปัตตานียะลานราธิวาสบึงกาฬCountries(Required)AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsYour length of stay in Phuket?(Required)Please advise your preferred time frame for surgery. As soon as after consultation Other Please Specify(Required)How you get to know BrightView Center? Friend Website Other Please Specify(Required)1. Information about your glasses or contact lensDo you wear glasses ? Yes No Which type of the glasses do you use now ? For far/distance vision only. For both far vision and reading. For reading only. None, I don’t need glasses. If you use glasses, do they have grounded-in prism? (These kinds of glasses are used for the correction of crossed-eyes or double vision.) Yes No Do you wear contact lenses? Yes No If yes, what type ? Rigid lens. Soft lens. Note: Please discontinue using contact lens for at least 2 weeks (for soft contact lens) or 4 weeks (for RGP) before your pre-operative examination appointment date. If yes, for how long have you used them ? Current Glasses or Contact Lens PrescriptionSphereRight EyeLeft EyeCylindricalRight EyeLeft EyeAdding for readingRight EyeLeft EyeContact lens PowerRight EyeLeft EyeInformation Regarding Your Vision Test and Spectacle Prescription: If you are not residing in Phuket, please obtain vision and prescription details from a local optometrist or spectacle shop. (If unsure, leave blank. We’ll reach out if more information is needed before your consultation.) 2. Your basic understanding about Refractive Lens ExchangeDo you have any knowledge about refractive lens exchange ? I don’t know anything. I know some basic information. I’ve studied about the procedure a lot, including the benefits and risks. 3. Information about general eye healthHave you ever received any previous eye surgery? No. Yes. Please specify(Required)Have you ever received any previous Laser vision correction (LASIK, LASEK PRK etc.)? No. Yes. Please specify(Required)Have you ever had any eye injuries? No. Yes. Please specify(Required)Have you ever been diagnosed with any of the following ocular problems? Check the box(es) Cataracts Crossed eyes Eye injury Glaucoma Lazy eye (Amblyopia) Macular degeneration Retinal detachment Drooping eyelid Other Please specify(Required)4. Underlying Disease?Underlying Disease? Heart Disease Hypertension Diabetes Mellitus Other Please Specify(Required)5. Please list any medications you are currently taking (including oral contraceptives, aspirin, over-the-counter medications, and home remedies):Do you currently use Blood thinners (such as: Aspirin, Warfarin)? No. Yes. Do you already use any eye medications? No. Yes. Please specify(Required)Are you allergic to any medications? No. Yes. Please specify(Required)Please identify your underlying disease (if you have diabetes, you need to control your fasting blood sugar to within an appropriate level e.g. below 170mg%):Information regarding your visual activitiesHow many hours per day do you spend on these activities?hour(s) for drivingPlease enter a number from 0 to 24.hour(s) for using a computerPlease enter a number from 0 to 24.hour(s) for reading books, newspapers etc.Please enter a number from 0 to 24.What % of your daily activities requires the use of glasses to see well? 100% (need glasses all the time) Over 50% 20% to 50% Below 20% 0% (do not need glasses at all) Do you need glasses to read, write, use a computer or perform activities where you need the ability to see close-up? No. Yes. Please check the box for activities for which you need glasses to see well:Group 1: Distance vision (>10 feet) Driving (street signs) Watching TV Sports Watching movies Recognizing faces Group 2: Mid-range vision (2-6 feet) Computers Cooking Shopping/Menus Driving (using the dashboard) Being able to talk to faces comfortably Group 3: Near vision (<2 feet) Books / Newspapers Medicine bottles Putting on make-up Sewing Desk work Using a mobile phone What is your primary occupation? I’m retired My work involves: Please list up to three favorite hobbies or interests:How often do you drive in the night time? Every day 1-2 times a week Not often Are you a pilot? No. Yes. Consent(Required) Please check this box to confirm that you have read, understood and agree to the Terms and Conditions and Privacy Policy above payment of Bangkok Hospital Phuket.
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