Optical Patient Intake Form

General Information

Please present all vision and major medical information to receptionist

Type of Address
Primary Language
Special Needs
Race
Ethnicity

Miscellaneous

Are you pregnant?
Are you breastfeeding?
Do you wear glasses?
Do you wear contact lenses?
Are you interested in contact lenses?
Are you interested in refractive surgery?
Do you perform fine or close-up work?
Are you outdoors all or part of the time?
Do you have trouble reading signs while driving at night?
Are you bothered by glare from overhead lighting?
Are you bothered by glare from a computer screen?
Are you bothered by glare from oncoming headlights at night?
Are your eyes sensitive in bright sunlight?

Review of Systems

Do you currently have, or have you ever had, any of the following problems or conditions?

Constitutional

Fever, Weight Loss/Gain

Cardiovascular

Heart Disease
High Blood Pressure
High Cholesterol
Stroke
Vascular Disease

Ears/Nose/Mouth/Throat

Allergies
Sinus Congestion
Post Nasal Drip
Chronic Cough
Dry Mouth

Respiratory

Asthma
Chronic Bronchitis
Emphysema
Sleep Apnea

Gastrointestinal

Constipation
Crohn's Disease
Hepatitis A
Hepatitis B
Hepatitis C
Ulcer/Reflux

Genito-Urinary

Bladder/Genitals/Kidney
Herpes Simplex
Prostate

Musculoskeletal

Joint/Muscle Pain
Osteo Arthritis
Rheumatoid Arthritis

Integumentary (Skin)

Skin Cancer
Skin Disease
Herpes Zoster/Shingles

Neurological

Headaches
Migraines
Multiple Sclerosis
Gout
Seizures

Psychiatric

Anxiety/Depression

Endocrine

Diabetes Type I
Diabetes Type II
Thyroid/Other Glands

Lymphatic - Hematologic

Anemia
Bleeding Problems

Allergic/Immunologic

Eczema
Hives
Lupus
Organ Transplant

Medical History

Ocular History

(mark yes or no to each question)

Age-related macular degeneration
Amblyopia (Lazy eye)
Blindness-one eye
Blindness-both eyes
Cataracts
Glaucoma
History of refractive surgery
Injury to the eye region
Keratoconus
Retinopathy
Strabismus (Crossed eyes)
Tear film insufficiency (dry eyes)

Patient's Past Medical History

(mark yes or no to each question)

Acquired Immune Deficiency Syndrome (AIDS)
Asthma
Arthritis
Cancer
Chronic obstructive lung disease (COPD)
Diabetes mellitus
Emphysema
Heart disease
Human immunodeficiency virus infection (HIV)
Hypercholesterolemia (high cholesterol)
Hypertensive disorder (Hypertension)
Seasonal allergy
Thyroid Dysfunction
Mental disorder
Rheumatoid arthritis

Family Health History

(mark yes or no to each entry. If yes, list which member including: mother, father, brother, sister, maternal/paternal grandmother or maternal/paternal grandfather)

Amblyopia (Lazy eye)
Blindness and/or vision impairment
Cataract
Macular Degeneration
Glaucoma
Retinal Disorder
Strabismus (cross eyes)
Arthritis
Cancer
Diabetes mellitus
Hypertension (high blood pressure)
Cardiovascular disease
Stroke

Social History

(check one for each question)

Are you a drug user?
Are you a:

Tobacco Use

(mark which one applies)

Are you a:

Medications

Medication Allergies

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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