Welcome to Laria Eye Care! Thank you for registering. Please answer as best you can and use proper capitalization/spelling since your responses import directly into your medical record. If answering for a child, please answer for them. Leave any spots blank if the answer is "no" or "none". Click "submit" at the bottom to save.

First name:
Last name:
Please list at least two phone numbers to reach you:
Cell Phone:
Home Phone:
Work Phone:
Birthday: MM/DD/YYYY
Sex Male Female
Names of parents or guardian:(if patient is under 18 yrs old)

Eye and Vision History: Please list all that apply for all following

Eye and vision History
How did you hear about our office (ie:Doctor, family, friend, Google, Yelp,insurance,ETC):
What brings you in for your EYE exam? ie:Blurry distance/near vision, failed vision screening, recommended by doctor, itching, blinking, headaches, getting close to TV/books/computer, ETC ):
Please list any EYE disease, surgery, serious injury or infection that you have had:
When was your last EYE exam approximately?
Are you currently seeing an ophthalmologist (or another optometrist)? If so, who?
Do you experience any EYE burning, itching, redness, tearing, rubbing or feel like something is in your eyes?
Please list any EYE drops you use ie:Blink, Refresh, Visine, Clear Eyes
How often do you use glasses? (ie:never, full-time, distance, reading, 6Hrs/day, ETC)
How old are your current glasses?
Please list any sports you do, hobbies, activities or if you need safety glasses for work. How many hours a day do you spend on computer,tablet or phone? ie:8hrs/day on computer
What type of work do you do? (For children: What is your grade in school?)
Where do you work? (For children: Where do you go to school?)
For children: List if you are in a special school, program, tutoring, behavioral, psychological speech, occupational or physical therapy?

Medical History

Medical History
When was your last medical exam?
Please list any medications you take:
Please list any allergies to medications?
Please list all seasonal/pollen/animal/food allergies?
Please list all vitamins and non-prescription medications you take regularly
List ALL of the medical problems you have:
Neurological (ie: Headaches, Seizures, Dizziness, Numbness)
Endocrine (ie: Thyroid, Diabetes)
Cardiovascular (ie:High Blood Pressure, Heart Pain, Arrhythmia, Heart Attack)
Blood (ie:High Cholesterol, Leukemia, Anemia)
Ear, Nose, Throat (ie:DEAF. Seasonal Allergies, Sinus Infec)
Respiratory (ie:Asthma, Bronchitis, TB, COPD)
General/ETC (ie: WHEELCHAIR, Unexplained Weight loss/gain, Fever)
Gastrointestinal (ie:Diarrhea, IBS, Constipation, Ulcer)
Reproductive/Urinary (ie:Infection, Inflammation, Pain, Hysterectomy, Urinary Reflux)
Muscles/Bones (ie: Arthritis, Muscle pain)
Skin (ie: Psoriasis, Eczema, Cancer, Sensitive Skin)
Immunologic (ie: HIV, Lupus, Rheumatoid Arthritis)
Psych(ie: ADHD,Autism,Anxiety,Downs,Speech Delay,Gross/Fine Motor Delay)

Family History

Family History
Do you have a family history of: (Write M for Mother, F or Father, B for Brother, S for Sister, GP for Grandparents)
Macular Degeneration
Retinal Detachments
Strabismus/Amblyopia (Lazyeye)
High Blood Pressure
Does anyone in your family have other vision/health problems? What?

Contact Lenses (Answer if you wear or want contacts)

How old is your current contact lens prescription?
What solution do you use ie:Revitalens,Biotrue,Optifree ?
About how may hours a day do you wear contacts? ie:none,12Hrs/day, 6Hrs/week?
How often do you replace your contacts ie:monthly,biweekly,every day?
How often do you sleep in your contacts?
What is your current contact lens brand if known?
What is your RIGHT contact lens Rx? (This is on the box ie: -2.00 OR -2.00-0.75x180) :
What is your LEFT contact lens Rx? (This is on the box ie: -2.00 OR -2.00-0.75x180) :

Ready to Submit?

After completing all the forms click the "submit data" button one time