Dynamic Vision Constantia Village

Step 1

Let's start with your details

This helps us prepare your file before your appointment.

Full name

Please enter your full name

Mobile number

Please enter a valid mobile number

Email address

Please enter your email address

Date of birth

Please enter your date of birth

South African ID number

Please enter a valid 13-digit ID number

Occupation

Please enter your occupation

Home address

Please enter your home address

Step 2

How do you use your eyes?

This helps us tailor your eye exam and lens recommendation to your actual lifestyle.

What do you mainly use your glasses for?

Select all that apply

Computer work

Reading

Driving

Outdoor / sport

Distance vision

All of the above

Please select at least one option

How many hours per day do you spend on a computer or phone screen?

0 – 2 hours Minimal screen time

2 – 5 hours Moderate use

5 – 8 hours Heavy digital use

8+ hours All-day screen work

Please select an option

Do you drive at night regularly?

Yes, regularly

Occasionally

Rarely or never

Please select an option

Do you spend significant time outdoors?

Yes — sport, gardening, outdoor work

Mostly indoors

Please select an option

Step 3

Your vision history

A little background helps us see the full picture.

Do you currently wear glasses or contact lenses?

Glasses

Contact lenses

Both glasses and contacts

I don't currently wear any

Please select an option

Are you currently wearing multifocal (progressive) lenses?

Yes — I'm used to them Wearing progressives comfortably for a while

Yes — but still adapting Recently prescribed, still getting used to them

Not sure / don't know

Please select an option

Do you have any of the following? (Select all that apply)

Diabetes

High blood pressure

Glaucoma (family history)

Dry eyes

Frequent headaches

None of the above

Step 4

One last thing

Almost done. This final section helps us plan the best outcome for you.

What is the main reason for your visit today?

Do you have a medical aid?

Yes — Discovery Health

Yes — other medical aid Momentum, Bonitas, Medihelp, etc.

No medical aid — paying privately

Please select an option

Medical aid name & plan (optional but helpful)

Medical aid membership number

When it comes to your eyewear, what matters most to you?

This helps us show you options that suit your priorities.

Best value for money Good quality at a competitive price

Balance of quality and cost Happy to invest in something good

Best available technology Performance is the priority

Please select an option

Your answers are confidential and shared only with your optometrist to help prepare for your appointment.

You're all set.

Thank you for completing your intake form. Your optometrist will review this before your appointment so we can make the most of your time together.

We look forward to seeing you. If anything changes before your appointment, please don't hesitate to contact us.

Staff record — do not share with patient