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 NameIf 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 computerDistance from computer VISUAL HEALTHDate of Last Eye ExamBy Whom?Do you currently wear glasses? Yes No Do you currently wear contact lenses? Yes No Any problems with your current contacts or glassesUse Sports Goggles/Safety Glasses Yes No PATIENT MEDICAL HISTORYName of Family PhysicianPhysician AddressDate of Last Physical Check-upCURRENT 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 RelationCataracts Personal Family Cataracts RelationCorneal Problems Personal Family Corneal RelationDyslexia Problems Personal Family Dyslexia RelationGlaucoma Problems Personal Family Glaucoma RelationLazy Eye/Eye Turn Personal Family Lazy Eye/Eye Turn RelationRetinal Problems Personal Family Retinal RelationMacular Degeneration Personal Family Macular Degeneration RelationMedicalADD/ADHD Personal Family ADD/ADHD RelationAllergies Personal Family Allergies RelationArthritis Personal Family Arthritis RelationCancer Personal Family Cancer RelationDiabetes Personal Family Diabetes RelationEczema/Rashes Personal Family Eczema/Rashes RelationHigh Blood Pressure Personal Family High Blood Pressure RelationHigh Cholesterol Personal Family High Cholesterol RelationKidney Personal Family Kidney RelationNeurological Personal Family Neurological RelationPsychological Personal Family Psychological RelationTBI/Stroke Personal Family TBI/Stroke RelationThyroid Personal Family Thyroid RelationHave 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 PhoneThis field is for validation purposes and should be left unchanged.
