Optometry Patient Information Form
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your Gender?
Male
Female
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Today's Eye Exam
Want Glasses
Want Contact Lenses
Eye Health Check
Other
Eye Injury
Right Eye
Left Eye
Both
None
Explain
Eye Turn or Lazy Eye
Right Eye
Left Eye
Both
Not Sure
None
Other
Glaucoma
Cataract
Macular Degeneration
Surgery
None
Other
Explain any of the above:
Family Ocular History:
Glaucoma
Macular Degeneration
Lazy Eye or Eye Turn
Other
None
Explain:
Patient Medical History:
Diabetes
Heart Condition
High Blood Pressure
Thyroid Condition
Cancer
Other
None
Explain Above
Family Medical History:
Diabetes
Heart Condition
High Blood Pressure
Cancer
Other
None
Explain Above
Are you currently taking any medication?
*
Yes
No
Medication (List purpose of medication if unsure of name)
Do you have any medication allergies?
*
Yes
No
Not Sure
Are you pregnant or nursing?
*
Yes
No
Signature
Submit
Should be Empty: