Neuro-Ophthalmology Intake Form
Please complete this form to help us understand your neuro-ophthalmology needs. All information is important for your care.
Full Name
*
First 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
*
Please Select
Vision loss
Double vision
Eye pain
Visual field changes
Abnormal eye movements
Other
Duration of Symptoms
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
Do you have any of the following symptoms?
Headache
Eye pain
Vision loss
Double vision
Drooping eyelid
Other
Relevant Medical History (check all that apply)
Diabetes
High blood pressure
Stroke or TIA
Multiple sclerosis
Thyroid disease
None of the above
Other
Current Medications (please list all)
Allergies (please list all drug or other allergies)
Referring Provider Name (if applicable)
Submit
Should be Empty: