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General Information

Insurance Information

        PRIMARY INSURANCE INFO                        SECONDARY INSURANCE INFO

Eyeglass History

 YesNo
Do you have problems with glare?
Do you have problems with night vision?
Are you allergic to nickel?
If you wear eyeglasses, are there certain times when you would rather not?
If you wear eyeglasses, does your spare pair have your correct prescription?
Do your sunglasses have UV (ultra-violet) protection?
Are your sunglasses your current prescription?

Contact Lens History

 YesNo
Do you currently wear contact lenses?
Have you ever tried to wear contact lenses?
Are you interested in changing or enhancing your eye color?
If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?
Are you having any problems with your current contacts?
Answer the questions below ONLY IF you currently wear contact lenses:
 Hours/DayDays/Week
What is your typical contacts wearing schedule?
 YesNo
Would you like to be evaluated for refractive laser surgery?
Would you like to be evaluated for a non-surgical method to correct your vision?

Medical History

 YesNo
Headaches?
Glare/Light Sensitivity?
Tired Eyes?
Amblyopia (lazy eye)?
Burning?
Dryness?
Epiphora (excess tearing)?
Eye Pain or Soreness?
 YesNo
Foreign Body Sensation?
Infection of Eye or Lid?
Itching?
Mucous Discharge?
Ptosis (drooping eyelid)?
Redness?
Sandy or Gritty Feeling?
Strabismus (crossed eyes)?
 YesNo
Blurred Distance Vision?
Blurred Near Vision?
Distorted Vision (haloes)?
Double Vision?
Floaters or Spots?
Fluctuating Vision?
Loss of Vision?
Loss of Side Vision?
Many diseases of the body have grave eye health consequences.  While the questions below may seem unrelated to your eye health, it is crucial to your care that we ask them.
 YesNo
Chronic fever / unexpected weight loss or gain / fatigue?
Ear/Nose/Throat problems (e.g., hearing loss, sinus problems, sore throat?)
Heart problems (e.g., chest pain, irregular heartbeat, swelling of feet, cold hands/feet?
Respiratory problems (e.g., shortness of breath, wheezing, coughing)?
Gastrointestinal problems (e.g., heartburn, abdominal pain, diarrhea, vomiting)?
Genitournimary problems (e.g., painful urination, blood in urine, sex organ problems)?
Musculoskeletal problems (e.g., muscle aches, joint pain, swollen joints)?
Skin problems (e.g., rashes, excessive dryness, growths or lumps)?
Neurological problems (e.g., numbness, weakness, headaches, blackouts)?
Psychiatric problems (e.g., depression, anxiety)?
Endocrine problems (e.g., frequent urination, thirst, feeling hot or cold much of the time)?
Blood/Lymph problems (e.g., bruising, weakness, unusual paleness, swollen glands
Immune problems (e.g., frequent infections; allergic reactions to foods, dust, pollens)?

Family/Social History


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