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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