WELCOME! Thank you for being our patient and trusting us with your vision and eyesight care.

Date

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Birthdate

Age

Spouse

Children / Ages

Email

Referred By

Employer

Occupation

Business Phone

Payment is due upon receipt of services.

Payment will be by

Cash
Check
Visa/Mastercard

Should you have vision insurance, a receipt will be provided for submitting a claim for reimbursement

VISION HEALTH HISTORY

Please fill out the following portions carefully, as your history has much bearing on the final diagnosis and prescription. You may wonder, since this is a visual examination, why some of these questions are asked. The nervous system which controls the other activities of the body also controls the visual mechanism. Diseases and other disorders of the body affect the proper functioning and health of the visual system. Conversely, the eyes, vision and “imaging” systems can have a great impact on healing both the mind and body.

Do you now wear glasses?

Yes
No

If yes, what age prescribed?

If not have you ever?

Do you now wear contact lenses?

Yes
No

Soft
Rigid

If you are not wearing contact lenses, have you ever?

Yes
No

Soft
Rigid

Have you had any refractive surgery?

Yes
No

When?

Type

Please share with us your main purpose in coming to our office today

Please list your primary visual complaints

Please list the issues that cause you the greatest amount of worry, stress or anxiety in your business or home life (i.e., time pressures, job security, etc.)

Please list any psychological symptoms or complaints (i.e. anger, depression, confusion, lethargy, procrastination, loneliness, etc)

I have the following physical symptoms or complaints (i.e. headaches, pressure in head, plugged or ringing ears, lightheadedness, clogged throat, back pain, bloated stomach, sore legs, etc.)

I am worried and concerned that if these symptoms are not cured, they will become worse in the following manner

Please mark those that apply to you NOW or IN THE PAST

Please list any other eye or general health problems

Are you doing anything to maintain or improve your eyesight (nutrition, eye exercises, orthokeratology, eye shaping, surgical eye shaping or other)?

Do you use a computer?

Home
Office
Both

How many hours a day do you use a computer?

Do you wear specially designed lenses for computer work?

Yes
No

Please describe any problems you have with your computer work (headaches, glare, focusing problems, etc)

What activities/sports/hobbies do you enjoy in your spare time?

Who is your General Physician?

Name

First Middle Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please list any medications you are taking

We appreciate your care in completing this questionnaire. The information you provided will permit me to make a complete optometric evaluation of your visual system in relation to your own specific needs.

New Patient Questionnaire – Adult – Online

New Patient Form

VISION HEALTH HISTORY

Who is your General Physician?

Strengthen Your Eyes
Not Just Your Glasses

New Patient Form

VISION HEALTH HISTORY

Who is your General Physician?

Strengthen Your Eyes Not Just Your Glasses

Strengthen Your Eyes
Not Just Your Glasses