Skip to content
028 9032 202089-91 Academy Street, Belfast, BT1 2LSMon - Fri 9am - 5.30pm | Thurs close at 9pm | Sat 9am - 1pm
Facebook page opens in new windowInstagram page opens in new windowLinkedin page opens in new window
Gift CardsCathedral Connect
Cathedral Eye Clinic
A Centre of Ophthalmic Excellence
Cathedral Eye ClinicCathedral Eye Clinic
  • Home
  • Laser Eye Surgery
    • VisuMax 800 SMILE Laser
    • Lasik
    • TransPRK
  • Cataract/Lens Surgery
    • Cataracts
    • Cross Border Patients
    • Monofocal and Multifocal Lenses
    • ICL Lens Implantation
  • Other Treatments
    • Eye Health
      • Dry Eye Disease
      • Glaucoma
      • Keratoconus – CAIRS Treatment
      • Electrolysis of Ingrown Eye Lashes
    • Treatment Journey
    • Cathedral Dermatology
    • Cathedral Health
    • Eye Nutrients
    • Double Vision and Squint
  • About Us
    • Our Team
    • Articles
    • Publications
    • Sponsorships
    • Video Testimonials
    • Robotics
    • Pricing
    • Cathedral Legal
  • Academy
    • CPD Events/Courses
    • Refractive Lens & Laser Surgery Made Easy!
  • Contact
Make an appointment
  • Home
  • Laser Eye Surgery
    • VisuMax 800 SMILE Laser
    • Lasik
    • TransPRK
  • Cataract/Lens Surgery
    • Cataracts
    • Cross Border Patients
    • Monofocal and Multifocal Lenses
    • ICL Lens Implantation
  • Other Treatments
    • Eye Health
      • Dry Eye Disease
      • Glaucoma
      • Keratoconus – CAIRS Treatment
      • Electrolysis of Ingrown Eye Lashes
    • Treatment Journey
    • Cathedral Dermatology
    • Cathedral Health
    • Eye Nutrients
    • Double Vision and Squint
  • About Us
    • Our Team
    • Articles
    • Publications
    • Sponsorships
    • Video Testimonials
    • Robotics
    • Pricing
    • Cathedral Legal
  • Academy
    • CPD Events/Courses
    • Refractive Lens & Laser Surgery Made Easy!
  • Contact

Patient Health Questionnaire

1Personal Details
2Contact Details
3Doctor and Optician Details
4Medical Questionnaire
5Consent
6Insurance
This field is hidden when viewing the form
Name(Required)
DD slash MM slash YYYY
Home Address(Required)
Do you take any regular medication?
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB, Max. files: 10.
    You may take a photo of your medication and upload the pictures here. Don’t worry of you can’t do this, instead just give us a few details in the previous box
    Do you take Warfarin?
    Please enter a number from 0 to 10.
    Do you have any allergies?
    Do you have any history of previous eye related conditions and or surgery?
    Eye conditions
    Do you wear glasses?
    Is there a prism in your glasses?
    Do you wear Hard or Soft Contact Lenses?
    Please select
    Do you experience glare from lights?
    Do you have an HGV driver’s license, or a pilot’s license?
    Do you have a pacemaker fitted?
    Do you play contact sports?
    Have you had any exposure to the rubella virus / a rash or anyone with a rash in the last 4 weeks?
    Are you pregnant or have you had a baby in the last 6 months?
    Consent to Share your Data(Required)
    It may be necessary communicate with your GP and your Optometrist. We therefore require your consent to communicate with him/her.
    Will you be using Health Insurance to cover the cost of your appointment?

    Treatments
    • VisuMax SMILE Laser
    • Lasik
    • Cataracts
    • ICL Lens Implantation
    • Monofocal and Multifocal Lenses
    • Phone numbers:
      028 9032 2020 (NI)
      01 4311094 (ROI)
    • Address:
      89-91 Academy St, Belfast BT1 2LS
    • Mail:
      info@cathedraleye.com
    • Clinic Opening Hours:
      Monday - Friday: 9:00am - 5:30pm
      Thursday Evening: 5:00pm - 8:00pm
      Saturday: 9:00am-3:00pm
      Sunday: Closed
    • Phone Line Opening Hours:
      Monday - Friday: 9:00am - 5pm
      Saturday: 9:00am-1:00pm

    Find us on:

    Facebook page opens in new windowLinkedin page opens in new windowInstagram page opens in new window
    Get in touch

    Submit

    Cathedral Eye Clinic
    © Cathedral Eye Clinic

    Privacy Policy | Call Recording and Data Collection

    Go to Top

    GIVE THE GIFT OF VISION
    THIS CHRISTMAS

    GIVE THE
    GIFT OF VISION
    THIS CHRISTMAS

    With our customisable gift cards

    With our gift cards

    ORDER NOW