New Patient Questionnaire – Adult – Online

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

Payment is due upon receipt of services.

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.

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.