AdultIntake Form Please fill out this intake form before your appointment. "*" indicates required fields Step 1 of 5 20% PATIENT INFORMATIONFirst Name* Last Name* Email* Home Phone*Cell PhoneOccupation* Date of Birth* Who may we thank for referring you to our office? Family/Friend Professional Referral Source's Name If not referred, how did you choose our office? LIFESTYLE QUESTIONSDescribe how you use your vision at work so we can make the best lens recommendations for you:What kinds of hobbies, sports and other interests do you have? Knowing this enables us to find the best vision correction for you:Do you work at a computer for long periods of time? Yes No Number of hours on computer Distance from computer VISUAL HEALTHDate of Last Eye Exam By Whom? Do you currently wear glasses? Yes No Do you currently wear contact lenses? Yes No Any problems with your current contacts or glasses Use Sports Goggles/Safety Glasses Yes No PATIENT MEDICAL HISTORYName of Family Physician Physician Address Date of Last Physical Check-up CURRENT MEDICATIONS (List name of medications including eye drops, vitamins & birth control pills)Allergies to medications? Yes No If so, please list:Do you smoke? Yes No Have you had any surgeries? Yes No FAMILY MEDICAL/EYE HISTORY (CHECK ALL THAT APPLY)OcularBlindness Personal Family Blindness Relation Cataracts Personal Family Cataracts Relation Corneal Problems Personal Family Corneal Relation Dyslexia Problems Personal Family Dyslexia Relation Glaucoma Problems Personal Family Glaucoma Relation Lazy Eye/Eye Turn Personal Family Lazy Eye/Eye Turn Relation Retinal Problems Personal Family Retinal Relation Macular Degeneration Personal Family Macular Degeneration Relation MedicalADD/ADHD Personal Family ADD/ADHD Relation Allergies Personal Family Allergies Relation Arthritis Personal Family Arthritis Relation Cancer Personal Family Cancer Relation Diabetes Personal Family Diabetes Relation Eczema/Rashes Personal Family Eczema/Rashes Relation High Blood Pressure Personal Family High Blood Pressure Relation High Cholesterol Personal Family High Cholesterol Relation Kidney Personal Family Kidney Relation Neurological Personal Family Neurological Relation Psychological Personal Family Psychological Relation TBI/Stroke Personal Family TBI/Stroke Relation Thyroid Personal Family Thyroid Relation Have you ever experienced, been diagnosed or treated for any of the following? Blurry Distance Vision Blurry Near Vision Burning Difficulty Driving at Night Double Vision Eye Fatigue/Strain Eye Infections Eye Injury Flash of Light Floaters/Spots Glare or Reflection Grittiness Headaches Itchiness Occasional Dryness Sunlight Sensitivity Tearing Uncomfortable Glasses EmailThis field is for validation purposes and should be left unchanged.
