Welcome to our New Patient Intake Form Step 2, please complete the form. Check everything and make sure you have filled out the required fields before going to the final step.

Do you presently wear glasses? YesNo

Do you presently wear contacts? YesNo

Have you ever worn contacts? YesNo

**MEDICAL HISTORY** (needs to be completed for the examination)

List any current medications and the reasons for taking them.

Do you presently wear contacts? YesNo

Do you suffer from any of the following
with glassescontacts if wornwithout correction
Distance Vision Blurry YesNo
Middle Distance Blur YesNo

(Dashboard/ Computer)

Near Vision Blur YesNo
Burning Sensation YesNo
Double Vision YesNo
Itchy Eyes YesNo
Pain In or Around Eyes YesNo
Eye Strain / Fatigue YesNo
Seeing Spots or Lines YesNo
Seeing Flashes YesNo
Dry/Scratchy/Watery Eyes YesNo
Problems with Focusing YesNo
Headaches YesNo
Glare YesNo

Dilated at that exam? YesNo

Do you or any BLOOD relatives currently suffer from or have a history of:

High Blood Pressure YesNo
Color Blindness YesNo
Cataracts YesNo
Diabetes YesNo
Glaucoma YesNo
Heart Disease YesNo
Allergies/Sinus YesNo
Amblyopia (lazy eye) YesNo
Macular Degeneration YesNo
Retinal Detachment YesNo
Eye Injury YesNo
Keratoconus YesNo
Endocrine YesNo
Arthritis YesNo
Gastrointestinal YesNo
Respiratory YesNo
Kidney/Bladder YesNo
Blood/Bleeding YesNo
Skin Disease (e.g. eczema) YesNo
Mental YesNo

Significant weight loss/gain/fatigue

Do you smoke? YesNo
If yes, how often? DailyOccasionally
If no, have you ever smoked? YesNo
Do you drink alcohol? YesNo
If yes, how often? DailyOccasionally
Do you use recreational drugs? YesNo
If yes, how often? DailyOccasionally

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