Ophthalmology Patient History Questionnaire
Please complete this questionnaire to help us understand your eye health history, current symptoms, and vision concerns before your visit.
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Reason for Visit and Current Eye Concerns
Main reason for visit
*
Current symptoms
*
Blurred vision
Eye pain
Redness
Itching
Discharge
Flashes/floaters
Light sensitivity
Double vision
Other
Duration of symptoms (days)
Which eye(s) are affected?
*
Left eye
Right eye
Both eyes
Eye History
Prior eye diagnoses or conditions
Cataracts
Glaucoma
Macular degeneration
Diabetic retinopathy
Dry eye
Amblyopia (lazy eye)
Astigmatism
Myopia (nearsightedness)
Hyperopia (farsightedness)
Other
Past eye surgeries or procedures
Current eye medications or eye drops
Last eye exam date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you wear glasses or other corrective lenses?
No
Yes, glasses
Yes, contact lenses
Yes, both glasses and contact lenses
Do you currently use contact lenses?
No
Yes, daily wear
Yes, extended wear
Yes, occasional wear
Other
If yes, what type of contact lenses or wear schedule do you use?
Medical and Family History
Current medical conditions
Diabetes
Hypertension
Autoimmune disease
Thyroid disease
Heart disease
High cholesterol
Asthma
Neurologic condition
Other
Current non-eye medications
Medication allergies
Family history of eye disease
Glaucoma
Cataracts
Macular degeneration
Retinal detachment
Amblyopia
Strabismus
Other
Submit
Should be Empty: