First Name:
*
Last Name:
*
Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Work Phone:
Home/Cell Phone:
Email:
Date of Birth:
Occupation:
Employer:
Date of Last Eye Exam:
Primary Vision Insurance:
Secondary Vision Insurance:
Primary Medical Insurance:
Secondary Medical Insurance:
How did you hear about our office?
I’m a returning Patient
Doctor Referral (Write name in box below)
Friend (Write name in box below)
Yellow Pages
Saw Sign / Building
Insurance listing
Web page
Other
Other:
Name of person who referred you:
MEDICAL HISTORY
HAVE YOU HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?
Gastrointestinal
Yes
No
Not Sure
Ears/Nose/Throat
Yes
No
Not Sure
Cardiovascular
Yes
No
Not Sure
Respiratory
Yes
No
Not Sure
High Blood Pressure
Yes
No
Not Sure
Neurological
Yes
No
Not Sure
Urinary
Yes
No
Not Sure
Muscles/Bones
Yes
No
Not Sure
Skin
Yes
No
Not Sure
Eyes
Yes
No
Not Sure
Endocrine
Yes
No
Not Sure
Blood/Lymph
Yes
No
Not Sure
Allergic/Immunological
Yes
No
Not Sure
Headaches
Yes
No
Not Sure
Mental
Yes
No
Not Sure
List your medications followed by what they are for (ex. Insulin/Diabetes). Medication / Purpose:
Are you diabetic?
Yes
No
If yes, year of diagnosis:
Are you allergic to any medication?
Yes
No
Medications I am allergic to:
Name of Primary Care Physician:
Date of last visit:
List any surgeries:
FAMILY HISTORY
DOES ANY OF YOUR IMMEDIATE FAMILY HAVE ANY OF THESE CONDITIONS?
High Blood Pressure
Yes
No
Who?
Diabetes
Yes
No
Who?
Glaucoma
Yes
No
Who?
Macular Degeneration
Yes
No
Who?
Retinal Detachment
Yes
No
Who?
Cataracts
Yes
No
Who?
PERSONAL EYE INFORMATION
Have you had any eye surgeries, injuries or serious conditions?
Yes
No
If yes, please describe:
Have you had any of these symptoms in the last week (check all that apply)?
Redness
Dryness
Sandy or gritty sensation
Itching
Excess watering or tearing
Excess mucous discharge
Blurred vision that clears upon blinking
Sensitivity to smoke
Sensitivity to wind
Sensitivity to computer glare
Sensitivity to air conditioning or heaters
Sensitivity to light
Sensitivity to contact lenses (dryness, irritation, etc.)
If you checked anything above, are your symptoms worse:
In the morning
Later in the day/evening
Same all day long
Do you ever wear (check all that apply)?
Prescription Glasses
Computer Glasses
Prescription Sunglasses
Non Prescription Sunglasses
Soft Contact Lenses
Hard (Gas-permeable) contact lenses
Non Prescription Reading Glasses
Tell us why you are here today (check all that apply):
New Glasses
New Glasses (if there is a change in prescription)
New Contacts
New Contacts (possibly but need more information first)
Eye Health problem
Eye Comfort problem
Academic problem
Other
If other please specify:
Do you use a computer?
Yes
No
Number of hours per day?
Are there any times when you wish your vision was better?
Yes
No
If yes, please describe below:
Is there anything we forgot to ask? Please tell us anything you would like us to know about your visit so that we can better serve you:
Submit