Patient Intake Form

Please complete all sections before your appointment

Personal Information
Contact & Demographics
Address
Employment
Notes
Billing Information
My billing address is different from my home address
* Indicates a required field
Visit Information
Eyewear
Do you currently wear glasses?
If yes, do you wear them for:
Do you currently wear contact lenses?
Current Symptoms
Do you see flashes of light?
Do you see floating objects (floaters)?
Do you have temporary blackouts of vision?
Do you have frequent headaches?
Do you have seasonal allergies?
Are you currently pregnant?
Do you use tobacco?
Do you drink alcohol?
Dry Eye Assessment

How often do you experience the following?

Dryness, Grittiness, or Scratchiness
How would you rate the severity?
Soreness or Irritation
How would you rate the severity?
Burning or Watering
How would you rate the severity?
Eye Fatigue
How would you rate the severity?
Medications & Allergies
Medical History
General Health — Do you have any of the following?
Eye History — Have you ever had?
Eye Surgery — Have you ever had surgery for?
Family History — Has anyone in your family ever had?
* Indicates a required field

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