PERSONAL DETAILS

Field is required!
Field is required!
Field is required!
Field is required!
Date of birth
Field is required!
What's your gender?
Field is required!
Do you have any of the following?
Field is required!
RELEASE OF INFORMATION AND PARTICIPATION CONSENT
Participant Release of Information Consent pursuant to Federal Privacy Act 1988 (AU) or Privacy Act 1993 (NZ)



  • I confirm that my participation in this Vision Check is voluntary.

  • I acknowledge that any personally identifiable health information obtained in conjunction with this health check will be protected and will only be used in accordance with this agreement and applicable laws pertaining to the use of personal health information.

  • I understand that any health information obtained, may be used to compile a deidentified aggregate report for my company/employer. My individually identifiable health information will not be shared with my employer.

  • I consent to the collection of data on my distance vision, near vision, colour vision and macular degeneration.

  • I understand that the data derived from the check is considered to be preliminary and for screening assessments only. The data collected does not constitute a diagnosis. The responsibility for initiating a follow-up examination to confirm the results of this screening and obtain professional assistance is mine alone and not that of my employer or any organisation associated with these vision checks.



  • I hereby give Bodycare Health & Wellbeing Pty Ltd consent to release the de-identified results of my health questionnaire as part of an aggregate result to the relevant department of my employer.
    Field is required!
    Field is required!

    VISION CHECK RESULTS

    Distance Vision

    Do you wear corrective lenses for distance vision?
    Field is required!
    Distance Vision - Left Eye 6/? (enter number in place of ? below)
    Field is required!
    Distance Vision - Right Eye 6/? (enter number in place of ? below)
    Field is required!
    Distance Vision - Both Eyes 6/? (enter number in place of ? below)
    Field is required!

    Near Vision

    Do you wear corrective lenses for near vision?
    Field is required!
    Near Vision - Left Eye N? (enter number in place of ? below)
    Field is required!
    Near Vision - Right Eye N? (enter number in place of ? below)
    Field is required!
    Near Vision - Both Eyes N? (enter number in place of ? below)
    Field is required!

    Colour Vision and Macular Degeneration

    Colour Vision Plates read - ?/12 (enter number in place of ? below)
    Field is required!
    How's your macular health?
    Field is required!

    Follow Up

    Are you under the care of an opthamologist or eye health specialist?
    Field is required!
    Is a follow up required?
    Field is required!
    Field is required!