Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian

Reason


Please choose from the menu options or select "Other" to type in your own text. Thank you!

Reason for Visit
Referred by
Last Eye Exam
Occupation

Glasses?Yes No
Contacts?Yes No
Vision TherapyYes No

Blurry @ Dist
Blurry @ Near
Seeing Double
Avoids Close Work
Short Attn Vis Tasks
Hard to remember what is read
Skip Words, Phrases or Lines of Print
Losing place when reading or writing
Spelling Problems
Using a finger or marker to keep place
Closer than normal reading dist
Farther than normal reading dist
Print blurs after a short time
Words seem to float around
Sudden Vision Loss
Spots or Floaters
Flases of light, sparks or stars
Problems seeing at night
Colored Halos around lights
Excessive blinking or rubbing
Squints frowns or scowls
Dizziness
Motion Sickness
Headaches
Eyes Dry
Eyes Red
Eyes Hurt
Eyes Itch
Gritty
Burn
Water
Sandy
Reversal of Words, Letters, Numbers
























Notes

Medical History


Please choose from the menu options or select "Other" to type in your own text. Thank you!

SelfFamily
Heart Disease
Diabetes
High Blood Pressure
High Cholesterol
Ears, Nose, Throat
Lungs, Breathing
Skin
Glands
Muscle, Bones, Nerves
Neurological, Mental
SelfFamily
Learning
Glaucoma
Eye Disease
Eye Surgery
Dyslexia
Turned Eye
A "Lazy" Eye
Color Vision
Blindness
Eye Injury















Additional Notes

Tobaccoyes no
Drugsyes no
Alcoholyes no

General Health
Primary Physician

Results of Last Medical Visits
Medications
Allergies to Medicines
Other Allergies

Submit Data

After Completing All Forms Submit Data on Final Tab