Questionnaire prior to Audit eye examination

Question Title

* 1. Full name:

Question Title

* 2. Age:

Question Title

* 3. Personal code:

Question Title

* 4. Do you wear glasses?

Yes, minus glasses

Yes, plus glasses

Yes, multifocal lenses

Question Title

* 5. Do you wear contact lenses?

Yes

Question Title

* 6. The reason for coming to the eye examination:

Question Title

* 7. Have you noticed a deterioration in your eyesight? If so, please specify when:

Yes

Question Title

* 8. Have you had the following problems with your eyes before? (You may choose multiple answers):

Keratoconus

Retinal disorder

Claucoma

Corneal disorder

Cataract

Ambliopia

None

Question Title

* 9. Have you had any eye traumas (injury/scarring)? If so, please specify, what and when it was:

Yes

Question Title

* 10. Do you have any medical conditions that we should be aware of? If so, please specify:

Yes

Question Title

* 11. Do you use any medications? If so, please specify:

Yes

Question Title

* 12. Has anyone in your family had an eye disease? If so, please specify:

Yes

Question Title

* 13. Do you have any additional comments or concerns related to the eye examination?

Question Title

* 14. Why did you choose KSA Vision Clinic for your eye examination?

Question Title

* 15. How did you hear about KSA Vision Clinic?

I did my own research and searched online

I received a recommendation from a friend, acquaintance, or family member

I saw a post or advertisement on social media (Facebook, Instagram)

I saw information through another channel (e.g., a banner on Delfi, an article in Postimees, a video on TikTok, an advertisement in a gym, etc. Please specify):

Question Title

* 16. Do you consent to the processing of your personal data?

I agree to the terms of personal data protection.