Full Name *

Age

Email *

Phone *

Medical Doctor

Last Eye Exam

Previous Eye Doctor

Diabetic?

Yes

No

If diabetic, # of years:

Referred By:

Friend

Brochure

Internet

Insurance

Doctor

Reason for this visit

Yearly exam to have glasses/contacts checked

Vision has changed

Diabetic Evaluation

Cataract Evaluation

Second Opinion

LASIK Evaluation

Any eye symptoms you have had:

Blurred vision

Dryness

Cataracts

Spots / floaters / flashes

Reading difficulty

Glare / Halos

Burning

Stinging

Itching

Tearing

Redness

Tired eyes

Pressure

Eye fatigue

Light Sensitivity

Headaches

Migraines

Diabetes

Poor night vision / Night driving difficulty

OTHER

List Medication/Pills:

List Eye Drops:

Drug Allergies (If yes, please list)

Pharmacy Name/Town

Past, Medical, Family Ocular History

Medical History & System Review

High blood pressure

Heart condition

Diabetes

Cancer

Arthritis

Respiratory disease

Ear / Nose / Throat Problems

Circulation Problems

Neurological Problems

Allergies

Other

List medical history If needed:

Ocular History

Cataracts

Self

Family

Glaucoma

Self

Family

Macular Degeneration

Self

Family

Dry Eyes

Self

Family

Amblyopia / Lazy Eye

Self

Family

Retinal Disorders

Self

Family

Infections

Self

Family

Eye Surgery

Self

Family

Laser Treatment

Self

None

List ocular history here if needed:

Social History

Please indicate your use of the following:

Alcohol: number of drinks per week

Smoking: number of cigarettes per day

Smoking: number of years

Do you drive?

Yes

No

Hobbies & special interests:

What type of eyeglass lenses do you currently wear?

Single Vision

Bifocal

Progressive

Are you satisfied with your current glasses?

Yes

No

If no, explain:

What type of contact lenses do you wear?

Soft

Disposable

Gas perm

How many hours per day do you use a computer?

1-3 hrs

3-6 hrs

6+ hrs

Questions:

Patient Signature

Clear

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