PATIENT INTAKE FORM

PATIENT NAME: DATE OF BIRTH: ______/______/______

REASON FOR YOUR VISIT TODAY: (Check all that apply) ❑ General Check-Up ❑ Cataract ❑ Want Contact Lenses ❑ Diabetic Eye Exam ❑ Glaucoma ❑ Other: ❑ Lost/Broken Glasses ❑ Macular Degeneration ❑ Blurred Distance Vision ❑ Dry Eyes ❑ Blurred Near Vision ❑ Want New Glasses Rx

Do you currently wear glasses? ❑ Yes | ❑ No Do you currently wear contacts? ❑ Yes | ❑ No

ALLERGY HISTORY/MEDICATION REACTION: (❑ None)

MEDICATION HISTORY: (❑None | ❑Diabetic Meds | ❑Blood Pressure Meds | ❑Cholesterol Meds | ❑Thyroid Meds | ❑Antihistamines | ❑Birth Control) LIST ALL:

CURRENT EYE SYMPTOMS: (Check all that apply) ❑ Blurred Vision Distance ❑ Floaters/Spots ❑ Loss of Central Vision ❑ Blurred Vision Near ❑ Fluctuating Vision ❑ Loss of Side Vision ❑ Burning ❑ Foreign Body Sensation ❑ Loss of Vision ❑ Distorted Vision ❑ Glare ❑ Mucous ❑ Double Vision ❑ Headaches ❑ Redness ❑ Dryness ❑ Infection of Eye Lid ❑ Sandy/Gritty Feeling ❑ Epiphora/Watery ❑ Itching ❑ Other: ❑ Eye Pain/Soreness ❑ Light Sensitivity

GENERAL HEALTH CONDITIONS: (Check all that apply and list specifics) ❑ Allergic/Immunologic ❑ Muscles/Bones/Joints ❑ Blood/Lymph ❑ Neurological ❑ Cardiovascular ❑ Nursing ❑ Ear/Nose/Throat/Mouth ❑ Pregnant ❑ Endocrine ❑ Psychiatric ❑ Gastrointestinal ❑ Respiratory ❑ Genital/Kidney/Bladder ❑ Skin ❑ High Cholesterol ❑ Other: SOCIAL HISTORY: Tobacco Use: ❑ Heavy Smoker ❑ Light Smoker ❑ Former Smoker ❑ Never a Smoker Alcohol Use: Do you drink? ❑ Yes | ❑ No

EYE CONDITIONS/FAMILY EYE HISTORY: (Check all that apply) SELF|FAMILY (list relation) Amblyopia ❑ | ❑ Blindness ❑ | ❑ Cataract ❑ | ❑ Color Blindness ❑ | ❑ Diabetic Retinopathy ❑ | ❑ Dry Eye Syndrome ❑ | ❑ Eye Injuries ❑ | ❑ Glaucoma ❑ | ❑ Macular Degeneration ❑ | ❑ Retinal Detachment ❑ | ❑ Strabismus ❑ | ❑ Other: ❑ | ❑ Specify “Other” Condition:

HEALTH HISTORY/FAMILY HEALTH HISTORY: (Check all that apply) SELF|FAMILY (list relation) Arthritis ❑ | ❑ Cancer ❑ | ❑ Diabetes ❑ | ❑ Heart Disease ❑ | ❑ High Blood Pressure ❑ | ❑ Kidney Disease ❑ | ❑ Lupus ❑ | ❑ Stroke ❑ | ❑ Thyroid ❑ | ❑

❑ Patient Signature | ❑ Parent/Guardian Signature Date

Parent/Guardian Name: (PLEASE PRINT):