Patient Information Form

Today's date:

Date of last exam:

Last name:

First name:

Init.:

Date of birth:

Age:

Sex:

Home address – street:

City:

State:

Zip:

Work address – street:

City:

State:

Zip:

Phone (home):

Phone (work):

Email address:

Employer:

Occupation:

Major purpose of this visit (i.e., glasses, contacts, LASIK, etc.):

Any problems with your current glasses or contacts:

Many eye problems are influenced by systemic conditions. Have you been or are currently treated for any of the following conditions? (choose yes or no for each)

Allergies:

Yes No

Heart disease:

Yes No

Arthritis:

Yes No

Hypertension:

Yes No

Bone disorder:

Yes No

Diabetes:

Yes No

Cancer:

Yes No

Stroke:

Yes No

Respiratory problems:

Yes No

Other:

Are you under the care of a physician?

Yes No

Name of physician:

List current medicines:

List any medicine allergies:

Have you ever been diagnosed with any of the following conditions? (choose yes or no)

Cataracts:

Yes No

Retinal disorders:

Yes No

Glaucoma:

Yes No

Eye injuries:

Yes No

Amblyopia (lazy eye):

Yes No

Eye surgery:

Yes No

Strabismus (turned eye):

Yes No

Other:

Many eye conditions run in families. Do any of your family members suffer from the following conditions? (choose yes or no)

Blindness:

Yes No

Diabetes:

Yes No

Cataracts:

Yes No

Hypertension:

Yes No

Glaucoma:

Yes No

Cancer:

Yes No

Other:

With regards to your eyes, do you experience any of the following conditions? (choose yes or no for each)

Redness?

Yes No

Uncomfortable contacts?

Yes No

Burning/itching?

Yes No

Uncomfortable glasses?

Yes No

Watery/tearing?

Yes No

Sudden loss of vision?

Yes No

Dryness?

Yes No

Nausea/dizziness?

Yes No

Eyestrain/headaches?

Yes No

Double vision?

Yes No

Blur at near?

Yes No

Spots/floaters?

Yes No

Reading problems?

Yes No

Flashes?

Yes No

Do you: (choose yes or no for each)

Have more than one pair of glasses?

Yes No

Wear your glasses full time?

Yes No

Enjoy spending time outdoors?

Yes No

Have prescription sunglasses

Yes No

Wear bifocals?

Yes No

If so, are you bothered by head tilting, restricted areas of vision, etc.?

Yes No

Work at a computer for long periods?

Yes No

Have problems with glare/reflection (especially driving at night)?

Yes No

Want information about thinner/lighter lenses?

Yes No

Have family members in need of eye care?

Yes No

Wear contacts, either now or anytime in the past?

Yes No

Want information about clearer and more comfortable contact lens designs?

Yes No

Have you ever had refractive surgery?

Yes No

Are you interested in more information regarding the current refractive surgery (e.g., LASIK) procedures?

Yes No

How did you hear about our office?

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