Patient Intake Form
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2Patient Intake Form
Welcome To Our Office.
All information will be kept confidential.
Please print and complete all items fully.
Mr.
Mrs.
Miss
Ms.
Dr.
SS# _______/_____/________
Today’s date _________/________/_________
Last Name ____________________________________ First _____________________ MI ____
Gender ______ DOB _____/_____/______
Address__________________________________________ Home Ph. (______)__________________ Work Ph. (______) _________________
City ___________________________________ State ____ Zip __________-_______ E-mail __________________________________________
Occupation _____________________________________________ Employer_______________________________________________________
Date of last eye exam _____________________ Were you dilated? Yes / No
Referred by ___________________________________________
Emergency contact name (s) _______________________________________ Phone number(s) (_______) ________________________________
Personal Eye Information
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Reason(s) for visit:
Eye Exam
First time contact lens fitting
Update for current contact lenses
Refit contact lenses
Medical problem
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Do you have any of the following? (circle all that apply or
check here if none apply)
Blurred Vision
Glaucoma Cataracts
Dry Eyes
Macular Degeneration
Retinal Detachment
Flashes / Floaters
Do you have any other eye conditions or problems?
Yes / No Describe ________________________________________________________
Have you had any eye injuries or surgeries?
Yes / No Describe ________________________________________________________
Do you wear glasses? Yes / No
Contact Lenses? Yes / No What type? _______________________________________________________
Do you use a computer? Yes / No
How many hours per day?______
Additional information ________________________________________
General Medical Information
What is your general health? __________________ Date of last physical exam _________________ Date of last tetanus shot _________________
Name of family doctor ________________________________ Phone # (______)_______________________
Pregnant? Yes / No / N/A
Do you have problems with any of these systems? (Please circle yes or no)
choose
Cardiovascular (Heart)
Yes / No
Urinary / Genital Yes / No
Endocrine (glands) Yes / No
High Blood Pressure
Yes / No
Muscles / Bones
Yes / No
Blood / Lymph
Yes / No
Ears / Nose / Throat
Yes / No
Integumentary (Skin) Yes / No
Allergic / Immunologic Yes / No
Respiratory (Lungs)
Yes / No
Nervous System
Yes / No
Headaches
Yes / No
Gastrointestinal
Yes / No
Psychiatric
Yes / No
Eyes
Yes / No
Please explain ___________________________________________________________________________________________________________
Diabetes Yes / No Type __________________ Date of diagnosis ______________ Last blood sugar count ___________ Last A1C _____________
Allergies to medication? Yes / No Which? ______________________________________ Reactions? ____________________________________
Other health problems _____________________________________________________________________________________________________
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Currents medication(s) (
check if none) ___________________________________________________________________________________
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Parent category: Business