Patient History Questionnaire
Name
First Name
Last Name
Address
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for today's visit
Do you wear contacts or glasses?
Glasses
Contacts
Both
DOB:
-
Month
-
Day
Year
Date
Are you planning on updating your eyewear ?
Glasses
Contacts
Both
Cell No:
Format: (000) 000-0000.
How did you hear about our clinic?
Employer
Referred by:
SSN:
Email
example@example.com
Eye Health and Medical History
Date of last eye exam:
-
Month
-
Day
Year
Date
Date of last physical exam :
-
Month
-
Day
Year
Date
Primary Care Provider:
Please check any of the following conditions you have or have had in the past
Blurred Vision - Distance
Eye Surgery
Eye Strain
Blurred Vision - Near
Loss of Vision
Double Vision
Flashes of Light Floaters
Poor Night Vision
Cataracts
Dry Eyes
Glaucoma
Retinal Disease
Poor Color Vision
Eye Infection
Headaches
Sensitivity to Light
Crossed / Lazy Eye
Eye Injury
Itchy, Watery Eyes
Other
Other
Please check all that apply if any of your blood relatives has any of the following and and their relationship to you
Cataracts
Macular Degeneration
Diabetes
Retinal Detachment
Glaucoma
Other
Relationship
Other
Please check any of the following conditions you have or have had in the past
AIDS/HIV
Cholesterol
High Blood Pressure
Shingles
Arthritis
Diabetes (Type)
Kidney Disease
Stroke
Asthma
Eczema / Rosacea
Migraine Headaches
Thyroid Problems
Blood Disorders
Epilepsy
Multiple Sclerosis
Tobacco Use
Cancer (Type)
Heart Disease
Pregnant Nursing
Tuberculosis
Chemical Dependency
Hepatitis (Type)
Seasonal Allergy
Other (Type)
Other
Medications
Prescribed or OTC (including eye drops)
Allergies
Please list your allergies to medications or substances
Life Style
Occupation
Do you........
Spend a lot of time outdoors
Currently have prescription sun wear
Use a computer on a daily basis, hours/days
Currently have computer eyewear
Spend lots of time reading / close up work
Have an interest in daily disposable contact lenses
Want information on laser vision correction
Hours/days
Submit
Should be Empty: