MEDICAL QUESTIONNAIRE Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastDate of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DatePERSONAL EYE INFORMATION:We would like to thank the person who referred you to our office: How did you hear about us? (friend, co-worker, family, google, insurance, etc.So we may better serve your vision needs, please complete the questions below regarding your visit to our office:Date of last eye exam:Do you wear glasses?YesNoFull timePart timeNear onlyDriving onlyComputerDo you wear contact lenses?YesNoBrand?Brand of Solution?Do you sleep in your contacts?YesNoIf yes, how often do you remove?How often do you dispose of your contact lenses?Your reason(s) for visiting our office today: (Please check all that apply)GENERAL CHECK UPBLURRED VISION FARBLURRED VISION NEAREYES FEEL DRYDOUBLE VISIONLOSS OF VISIONSTYES/ CHALAZIONHEADACHESLIGHT SENSITIVITYEYES WATERFLASHES OF LIGHTFLOATING SPOTS IN EYESREDNESSWANT CONTACT LENSESLOST OR BROKE GLASSESEYES ITCHPAIN IN EYESNIGHT VISION PROBLEMSTIRED EYESPrimary Care Physician:(For Diabetics Only) Phone #Are youType 1Type 2GestationalPrediabetesHow long have you been diabetic?Results of last Finger-Stickleave blank if unknownLast A1C: (3 month blood test your doctor does) leave blank if unknownDo you feel like your diabetes is under control? YesNoMedicationsleave blank if n/aDrug Allergiesleave blank if n/aMajor Surgeriesleave blank if n/aDilation informed consent: Dilation is recommended every other year, even in healthy eyes. First visit to our office. Dilation may be required more frequently by your eye doctor for many ocular and systemic conditions. Many serious and sometimes vision threatening conditions cannot accurately diagnosed or detected without dilation. Dilation will make you light sensitive, and will make your distance and near vision blurry (mostly near). Driving is usually safe when dilated, and the patient assumes all risks of operating a motor vehicle, as well as any other visually demanding tasks, while dilated.DO YOU WISH TO BE DILATED TODAY?YesNoIF NecessaryDo you smoke/ chew/ vape?YesNoDo you drink alcohol?YesNoDo you use illegal drugs?YesNoCommentSubmit
