Telling the optometrist about me
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- Gwendolyn Jackson
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1 Telling the optometrist about me Information about me and my sight Version 2 - Nov 2010 lease fill in this form and take it with you to your eye test. Your supporter can fill in this form with you. It s okay to ask them to write on the form. lease also take these things with you to your eye test: Your glasses if you have any The prescription from your last eye test Name R L Optician Date rescription SH CYL AXIS RISM ADD Evidence of any benefits you get Your Health Action lan if you have one. If you are filling in this form for someone else please fill in this section Your name and role: Your address: hone number: address: SeeAbility is the operating name of The Royal School for the Blind founded in Registered Charity Number SeeAbility No part of this document can be altered or changed without permission age 1
2 Your details: Your name: Your address: hone number: Date of birth: NHS Number: National Insurance Number: Your G s name and address: About your e: Where and when was your last eye test? Tell us the results of your eye test. Do you have glasses? If please take you glasses with you to the eye test. Tell us what you wear your glasses for. Do you have any problems with your glasses? SeeAbility No part of this document can be altered or changed without permission age 2
3 Do you have any problems seeing? no don t know? sometimes! X If, please write what the problems are? Are you registered blind / severely sight impaired? Are you registered partially sighted / sight impaired? Have you ever been to hospital about problems with your e? Ambulance If, what was the problem? which hospital did you go to? Has anyone in your family had serious eye problems? For examples has anyone had glaucoma, cataracts or diabetes? If, please write say who has had problems and what problems they ve had. Who What problem SeeAbility No part of this document can be altered or changed without permission age 3
4 More about you Do you use a wheelchair? no X sometimes! If, ask about access into the optician shop and the eye test room. Do you have any health problems or disabilities? no X If, please say what they are. Do you take any TABLETS medication? no X don t know? If please take information about your medication with you to the eye test. Are you Deaf or Hard of Hearing? no X If please tell the optometrist about your hearing. Do you find it hard to communicate?? no X sometimes! What helps you communicate? Tell us if you use things like: Makaton, an interpretor, pictures, gestures, closed questions with / no answers. SeeAbility No part of this document can be altered or changed without permission age 4
5 About your eye test When you have your eye test the optometrist will need to look at your e. They will also do some tests to check how well you can see. The information you give the optometrist will help them to test your e. Can you say or sign the names of letters on an eye test chart? T T Can you say or sign names of pictures on a chart like house, fish or car? House Can you point to a letter or picture on a card that is the same as a letter or picture on a chart on a wall? Will you be able to wear test frames on your face? SeeAbility No part of this document can be altered or changed without permission age 5
6 Will you be okay if the optometrist were to cover your e one at a time? Can you understand better and worse? better worse Would you be able to put your chin on a shelf in front of a machine? You will need to keep your head still for a while. Will you be okay if the optometrist came close to you? Will you be okay if the optometrist came close to you and shone a bright light in your eye? SeeAbility No part of this document can be altered or changed without permission age 6
7 Will you be okay with a machine that will measure your eye pressure? This machine might blow air into my eye or gently touch my eye. This will not hurt but it might make you jump. Will you be okay if the optometrist needs to put drops in your e? Some eye drops may sting for a bit, or make it hard to see for a short time. You can ask the optometrist about this. lease tell us any other information we may need to know here. Designed by The Clear Communication eople Ltd, mike@communicationpeople.co.uk. Some photosymbols used go to SeeAbility No part of this document can be altered or changed without permission age 7
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