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028 9032 2020 89-91 Academy Street, Belfast, BT1 2LSMon - Fri 9am - 5.30pm | Thurs close at 9pm | Sat 9am - 1pm

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Cathedral Connect

Cathedral Eye Clinic

A Centre of Ophthalmic Excellence

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Patient Health Questionnaire

1Personal Details

2Contact Details

3Doctor and Optician Details

4Medical Questionnaire

5Consent

6Insurance

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Salesforce Contact ID

Name(Required)

Title First Name Middle Name Last Name

Date of Birth(Required)

DD slash MM slash YYYY

Sex(Required)

Your Occupation(Required)

You Email address(Required)

Mobile Phone Number(Required)

Home Phone Number

Home Address(Required)

Street Address Address Line 2 Town or City County Post Code Country

Your Doctor's Surgery Name(Required)

Your Doctor's Name

Optician's Practice Name(Required)

Optician Name

Do you take any regular medication?

No

Yes

Regular Medication Details

Medication Pictures

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 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?

No

Yes

Please enter the latest INR level

Please enter a number from 0 to 10.

Do you have any allergies?

No

Yes

Please select allergies

If you suffer from an allergy not listed, please specify

Do you have any history of previous eye related conditions and or surgery?

No

Yes

Please provide details here

Eye conditions

Do you wear glasses?

No

Yes

Is there a prism in your glasses?

No

Yes

Don’t know

Do you wear Hard or Soft Contact Lenses?

No

Yes

When was the last time you wore them?

Do you suffer from any of the following?

Please select

Do you experience glare from lights?

No

Yes

Do you have an HGV driver’s license, or a pilot’s license?

No

Yes

Do you have a pacemaker fitted?

No

Yes

Do you play contact sports?

No

Yes

Have you had any exposure to the rubella virus / a rash or anyone with a rash in the last 4 weeks?

No

Yes

Are you pregnant or have you had a baby in the last 6 months?

No

Yes

Consent to Share your Data(Required)

Please Tick to Confirm your Consent

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?

No

Yes

Insurance Company

Membership Number

Authorisation Code or Reference

Treatments

VisuMax SMILE Laser
Lasik
Lasek – PRK
Cataracts
ICL Lens Implantation
Monofocal and Multifocal Lenses
Rehabilitation Medicine

Phone numbers:
028 9032 2020 (NI)
01 4311094 (ROI)
Address:
89-91 Academy St, Belfast BT1 2LS
Mail:
info@cathedraleye.com
Business hours:
Monday - Friday: 9:00am - 5:30pm
Thursday Evening: 5:00pm - 8:00pm
Saturday: 9:00am-1:00pm
Sunday: Closed

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