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Optometry Patient Intake Form

Thank you for taking the time to complete this form in its entirety.
Patient Information
Name
First Last
Date of birth
Gender
Marital status
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone (Home)
Phone (Work)
Phone (Cell)
Occupation
What is the reason for your visit?
- Yearly checkup
- Blurred vision
- Dry eyes
- Eyestrain
- Eye pain
- Sever sensitivity to light
- Headaches
- Poor night vision
- Bothersome night glare
- Double-vision
- Total loss of vision
- Redness
- Burning
- Itching
- Tearing
- Discharge
- Infection
- Flashes of light
- Floaters
- Grittiness
- Other
Other reason for visit
How did you hear about us?
Family Doctor
Name
First Last
Phone
Emergency Contact
Name
First Last
Phone
Relationship
Eye-Related Medical History
Do you or any family members have a history of the following eye problems?
- Amblyopia (Lazy Eye)
- Regular Headaches
- Double Vision
- Difficulty Judging Depth
- Diabetic Retinopathy
- Eye Surgery
- Eye Injury
- Itchy Eyes
- Dry Eyes
- Cataracts (Hazing of internal lens)
- Keratoconus
- Glaucoma (Tunnel vision)
- Macular Degeneration
- Color Blindness
- Retinal Detachment
- Retinitis Pigmentosa
- Ocular Melanoma
- Strabismus (Eye Turn)
- No reported eye problems
- Other
Other eye-related problems
When was your last eye exam?
Do you have difficulty with any of the the following?
- Seeing up-close
- Seeing the computer
- Seeing far away
- Other
Other vision difficulties
Where did you get your last pair of glasses?
What do you value most in glasses?
- Technology
- UV Protection
- Appearance
- Ease of use
- Durability
- Cost
- Other
Other things you value most in glasses
Contact Lenses
Do you or have you ever worn contact lenses?
- Yes
- No
Are you interested in wearing contact lenses?
- Yes
- No
- Maybe
Do you ever sleep in your contact lenses?
- Yes
- No
Are you happy with your contact lenses?
- Yes
- No
Why are you unhappy with your contact lenses?
How often do you wear contact lenses?
- 5-7 times per week
- 1-3 times per week
- Less than once a week
How often do you dispose of your contact lenses?
- Daily
- Weekly
- Bi-Weekly
- Monthly
What brand of contact lenses do you wear?
Which contact lens cleaning solution do you use?
- Clear Care
- Opti-Free
- Biotrue
- Not sure
- Other
Other lens cleaning solution
What do you value most in contact lenses?
- Comfort
- UV Protection
- Breathability
- Convenience
- Health
- Cost
- Other
Other things you value most in contact lenses
Which of the following services will you be needing?
- Annual Comprehensive Visit (Eye Health and Glasses Update)
- Contact Lens Update (Renewing CL Rx)
- New Contact Lens Fitting (Training and Evaluation)
- Dry Eye Consultation and Therapy
- Ortho K (Corneal Reshaping and Nearsighted Control)
- Corneal Prosthetic (Specialty fitting for corneal degenerative disease)
- Refractive Surgery Consultation
- Glaucoma Evaluation
- Eyewear Consultation (Appointment with Optician)
- Other
Other services needed
General Medical History
Do you or any family members have a history of the following health problems?
- High Blood Pressure
- High Cholesterol
- Thyroid Disease
- Allergies
- Multiple Sclerosis
- Anxiety
- Asthma/COPD
- Arthritis
- Autoimmune disease
- Blood clots
- Bowel disease
- Cancer
- Depression
- Diabetes Type 1
- Diabetes Type 2
- Heart attack
- Stroke
- HIV-AIDS
- Kidney Disease
- Kidney Stones
- Liver disease
- Neurologic disorder
- No Reported health problems
- Other
Other general health problems
List current medications
Medication name Dosage frequency Reason for taking
List current allergies
Allergy Medication Reaction
List past surgeries and dates
Body area Type of surgery Date
List lifestyle activities (ie. Intoxicants, Smoking, etc)
Activity Frequency Years
Review of Systems
Do you have any of the following symptoms today?
- Neck Pain
- Headache
- Facial pain/numbness
- Fevers/Chills
- Unexplained weight loss
- Night Sweats
- Dizzy/Lightheaded
- Ear ringing
- Hoarseness
- Nose bleeds
- Blood in Sputum
- Persistent Coughing
- Shortness of breath
- Angina/Chest Pain
- Ankle swelling
- Heart Palpitation
- Leg pain with walking
- Wake short of breath
- Abdominal pain
- Blood in stool
- Bloating
- Constipation
- Diarrhea
- Heartburn
- Nausea/Vomiting
- Blood in urine
- Heavy/Painful menses
- Swollen glands
- Blood Clots
- Bleeding easily
- Joint Pain / Swelling
- Breast lump
- Skin rash
- Depression
- Poor sleep
- No Symptoms
- Other
Other symptoms
Insurance
Do you have dental insurance?
- Yes
- No
Insurance company name
Certificate / ID number
Group policy number
Are you a dependant?
- Yes
- No
Relationship to the insured
Name of insured
Insured date of birth
Authorization
Consent
I give consent to the release of relevant findings to other health care providers, the use of my email for methods of communication to and from this office, and this office for direct billing to my insurance, on my behalf, when available.
Signature

Medication name	Dosage frequency	Reason for taking

Allergy	Medication	Reaction

Body area	Type of surgery	Date

Activity	Frequency	Years

Optometry Patient Intake Form

Patient Information

Family Doctor

Emergency Contact

Eye-Related Medical History

Contact Lenses

General Medical History

Review of Systems

Insurance

Authorization