NTU Eye Screening Registration

Full Name *

NRIC / Passport No *

For Verification

Date of Birth *

Occupation

Department *

Company

Home Phone

Mobile Phone *

Email *

Address

Preferred Date *

20 Sept 2011

21 Sept 2011

22 Sept 2011

Preferred Time *

Remark

Addtional Questions

1. Do you wear spectacles?

Yes

If Yes, Your spectacles are currently used:

All the time(Constantly)

For reading only

For using computer only

If No, can you see clearly?

Yes

2. Your current spectacles prescription

Please complete this information (Leave blank if you are unsure)

Right Eye

SPH

CYL

AXIS

PRISM

ADD

Left Eye

SPH

CYL

AXIS

PRISM

ADD

Check this if following applies to your situation

You are currently using Progressive/Bifocal Lenses

You cannot see clearly with them

Please tick if you currently use more than one pair of spectacles

3. Do you wear contact lenses?

Yes

What type do you currently use?

Contact Lens Type (Others)

Please fill up the following

Leave blank if you are unsure

Right Eye

DIA

SPH

CYL

Left Eye

DIA

SPH

CYL

Choose one of the following that is best describe your Contact Lenses Experience

I am very happy with the contact lenses that I am using currently

I want a recommendation from IGARD

Use more than 1 Brand

Please tick here if you currently use more than 1 brand/type of contact lens

Eye Health

Do you have any information which you like to add?

4. Health History

When was your last eye test?

Less than 1 year

Less than 2 years

More than 2 years

Any Information regarding your Routine Check Up/Others

Have you had eye surgery before

Right Eye

Left Eye

Both Eyes

Never

Eye Surgery Remarks

Do you have diabetes?

Yes

Family History

Year Diagnosed

Do you have HBP?

Yes

Family History

Year Diagnosed

Are you on constant medication?

Yes

Medication Remarks

NTU Eye Screening Registration

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