*What is your reason for seeking care at this time?
*Approximately how long ago was your last eye exam?
*By what doctor or office?
*Do you now wear glasses or contact lenses?
If contacts are worn:
What type?
Average wearing time per day (hrs.):
Do you wear them over night?
Name of solutions used to care for them?
Have you ever had any eye disease, eye injury, or eye surgery?
If yes, please explain:
Check any of the following eye symptoms or problems that you are have experienced:
Flashes of Light
Floaters
double vision
turned eye
itching
burning
dryness
redness
lazy eye
cataracts
glaucoma
eye strain
light sensitivity
blurred vision w/correction
Check any of the following medical conditions that you have?
Allergies
High blood pressure
Heart disease
Lung problems
Diabetes
Frequent Headaches
Thyroid Problems
No Health Problems
Other:
Personal Physician(s):
Please list any medications you are currently taking:
List any allergies to medications:
Does anyone in your family have any eye disease or health problems (i.e. glaucoma, macular degeneration, eye turns, diabetes, high blood pressure, etc.)?
Yes
No
If yes, please list who & what:
I would like more information about:
contact lenses
eye disease prevention
turned eye
refractive laser surgery
glaucoma
cataracts
Other:
Exams are to be paid for at the time of service. Materials are requested to be paid in full when ordered, and require a minimum of 50% deposit at the time of order, the balance to be paid when dispensed. No materials are dispensed until paid in full.
