Patient Name*
Today’s Date*
Sex at Birth*
Last Eye Doctor/Location*
Date of last eye exam*
Primary Care Physician/Location:
Date of last physical exam*
Occupation*
What is the main reason for your visit today?*
Do you have any other visual/ocular problems?
Do you primarily wear glasses?(Mark all that apply)*
How old are your current glasses?
Do you wear contact lenses?*
Are you interested in a new contact lens design?
Are you interested in refractive surgery (laser or cataract) options?
How many total hours per day do you use a computer, cell phone, tablet or play video games?*
Do you use computer glasses?*
Are you interested in special glasses to make computer work easier?*
What sports/hobbies do you participate in?*
Do you wear any special eyewear for your sport/hobby?*
Do you currently wear sunglasses?*
Are you sensitive to bright lights?*
Please check off the following for SEVERITY and FREQUENCY of dry eye symptoms:
Severity of Symptoms
Legend
0 - No problems1 - Tolerable (not perfect, but not uncomfortable)2 - Uncomfortable (irritating, but does not interfere with my day)3 - Bothersome (irritating and interferes with my day)4 - Intolerable (unable to perform my daily tasks)
Dryness, grittiness or scratchiness*
Soreness or irritation*
Burning or watering*
Eye Fatigue*
Frequency of Symptoms
Legend0 - Never1 - Sometimes2 - Often3 - Constant
Please check the boxes that apply. Unchecked boxes will mean “no”.
Allergy*
Constitutional*
Cardiovascular*
Endocrine*
Gastrointestinal*
Genitourinary*
Head*
Hematologic/ Lymphatic*
Immunologic/ Integumentary (Skin)*
Musculoskeleta*
Neurologic*
Psychiatric*
Respiratory*
Conditions*
Surgeries*
Ocular*
Medical*
Name
Dose
Purpose
*Please include over the counter medications, eye drops, vitamins, contraceptives, and herbal supplements.
I verify that the information contained on this page is current.
Patient Signature*
Date
All EyeCare Services
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At A+ Vision Optometry, we provide the highest quality eye care to all our patients. Schedule your appointment today.
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