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Parent's Name (If patient is child):
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If a student, Grade:
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Occupation:
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Have you had your eye exam at this office before
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Reason for seeking vision care at this time?
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Changes to medical & ocular history?
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Visual Symptoms (select each you have had)
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Health History (Check each you have had)
• • •
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Family Health History (Check if family has had)
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Do you consider your health
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Last visit to your medical physician?
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Medical Physician's Name
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Are you pregnant?
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Select if a woman
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Are you breastfeeding?
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If yes, please explain
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Do you smoke, drink, or use drugs?
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If yes, what drugs are you taking?
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Are you taking medication or drugs?
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If yes, which?
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Are you allergic to any medications?
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If yes, please explain
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Any serious eye disease, injury, or surgery?
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What is your previous eye doctor's name?
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When was you last eye exam?
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If yes, which type?
• • •
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Do you wear contact lenses?
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Language Assistance Response
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Declined survey?
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Preferred Written Language
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Preferred Spoken Language
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Other Preferred Written language
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Other Preferred Spoken language
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