Online Patient Form

List any vision or eye health complaints you are currently having such as:

Blurred vision, headaches, eyestrain, double vision, or losing your place when reading
Itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
Seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

Check the box for any conditions that apply:

Condition

You

Mom

Dad

Sib

None

Describe (type, when diagnosed, which eye(s), treatment, etc)

Glaucoma

Macular Degeneration

Retinal problems

Cataracts

Lazy Eye/Eye Turn

List any major eye injuries, infections or surgeries and approximate dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

What are your hobbies?

How many hours per day do you typically spend on digital devices?

How many hours per day do you typically spend reading?

How many hours per day do you spend outdoors?

Do you have sunglasses?

Are you interested in being fit for or receiving a prescription for contact lenses?

What type of glasses do you currently use?

Other type of glasses?

Do you have a current pair of glasses for when you are not wearing contacts?

Patient Information