Name (Last, First, Middle Initial)
Age
Date of Birth
Address
City
State TN AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code
Insurance Company
Group ID #
Subscribers ID #
Subscribers Date of Birth
Home Phone Number
Work Phone
Cell Phone
Parent's Name (if minor)
Occupation
Employer
What is the main problem that caused you to schedule an appointment?
When was your last eye exam?
Name of last eye doctor?
Are you interested in contact lenses today? yes no
Types of contacts you are interested in?
Are you being treated by a physician for any medical condition?
What prescriptions or over the counter medicine do you currently take and why do you take them?
Name of your family doctor?
Last checkup?
Do you wear glasses? yes no
Have you ever had eye surgery? yes no
Do you wear contact lenses? yes no
Have you ever had a serious eye injury? yes no
Have you ever been told you have glaucoma? yes no
Do you have any blood relatives with glaucoma? yes no
Have you ever been told you have cataracts? yes no
Do you have any blood relatives with cataracts? yes no
Have you ever been told you have diabetes? yes no
Do you have any blood relatives with diabetes? yes no
Have you ever been told you have high blood pressure? yes no
Do you have any blood relatives with high blood pressure? yes no
Are you allergic to any medications? yes no
If yes, which type?