Relex Smile Medical Questionnaire

PLEASE NOTE: It is necessary to provide us with all medication you use for all health problems in order to correctly indicate you to a surgery. In case if false, not complete information or concealed medical history is provided your treatment might be cancelled with no financial refund.

Name and Surname: *

Country:

Phone:

E-mail: *

Considered date for the treatment: *

Date of Birth: *

Since when have you been wearing glasses?

Do you know your prescription for glasses?

Do you wear contact lenses?

YesNo

Do you know your prescription for contact lenses?

1. Are you fit and well?

YesNo

2. Have you had any eye operations in the past?

YesNo

3. Do you use any eye drops?

YesNo

4. Do you regularly attend hospital for your eyes?

YesNo

5. Do you suffer from any auto immune disease?

YesNo

6. Have you had any operation in the past? (heart, kidney etc.)

YesNo

7. Do you suffer from a lazy eye (amblyopia)?

YesNo

8. Have you ever had any eye injury?

YesNo

9. Have you ever had herpes in your eyes?

YesNo

10. Do you suffer from heart disease, or have you ever had problems with your heart?

YesNo

11. Are you being treated for high blood pressure?

YesNo

12. Is anyone of your relatives being treated for glaucoma?

YesNo

13. Do you suffer from any respiratory disorder?

YesNo

14. Do you receive treatment for diabetes?

YesNo

15. Are you being treated for a nervous disease?

YesNo

16. Have you ever been admitted to hospital or been treated / taken medication for a mental illness?

YesNo

17. Are you pregnant?

YesNo

18. Are you breast-feeding?

YesNo

19. Have you ever suffered from squinting?

YesNo

20. Do you suffer from any alergy?

YesNo

21. Do you take any medication?

YesNo

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