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602-547-3255
patientcare@accenteyes.com

16020 North 35th Avenue
Suite 2
Phoenix, AZ 85053

OUR OFFICE HOURS

MON - THUR - 9:00AM - 6:00PM
TUE - 9:00AM - 6:30PM
FRI - 8:00AM - 2:30PM

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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

    ExcellentGoodFairPoor




    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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