Online Patient Forms

Patient Information

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Primary Medical Insurance


Front of the card preview

Back of the card preview

Medical History

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Eye History

Contact Lens Wearers only:

Medical History


Do you have any of these medical conditions?


Family Medical History

Does anyone in your family have any of these medical conditions?


Family Eye History

Does anyone in your family have any of these eye conditions?


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Review Of Systems

Social History

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Dry Eye Disease

Enviornmental Factors
Systemic Conditions
Systemic Meds
Ocular Meds
Artificial Tears Times/day
Signs
Contact Lenses

Frequency Legend: (rate on a scale of 3: 0 = Never, 1 = Tolerable, 2 = Often, 3 = Consistant)
Severity Legend: (rate on a scale of 4: 0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Symptoms
Frequency
of Symptoms
Severity
of Symptoms
Symptoms
at This Visit
Symptoms
Within Past
72 Hours
Symptoms
Within Past
3 Months
Dryness, Grittiness, Scratchiness
Yes No
Yes No
Yes No
Soreness or Irritation
Yes No
Yes No
Yes No
Burning or Watering
Yes No
Yes No
Yes No
Eye Fatigue
Yes No
Yes No
Yes No
Fluctuating Vision
Yes No
Yes No
Yes No

OSDI Legend: (rate on a scale of 4: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Always)
Experienced In
The Following? 		Limited In Performing
The Following?		 Uncomfortable
In The Following?
Sensitivity To Light? Reading? Windy Conditions?
Gritty Feeling? Driving At Night? Low Humidity?
Painful Or Sore? Computer Use? Air Conditioning?
Blurred Vision? Watching TV? Poor Vision?

Office Policies Agreement

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.


Acknowledgement of Pupil Dilation
Because some medical conditions first show up in the eye, the retina is best viewed with a dilated pupil. The doctors at 20Twenty Eyecare recommend a pupillary dilation once every two years, however, certain medical conditions require a dilated exam more often.

Please talk with our doctors or a staff member if you have any questions.

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