Intake Form

Date :

Gender :

Name :

Date of Birth :

Age :

Home Address :

City :

State :

zip :

TELEPHONE NUMBER : Home :

TELEPHONE NUMBER : Cell :

TELEPHONE NUMBER : Work :

Employer :

Occupation :

E-mail :

How did you hear about us ? :

Do you have EYEMED VISION PLAN ? :

Do you have MEDICAL INSURANCE ? :

Company :

NAME OF INSURED :

DATE INSURED :

Vision Plans cover "well vision" exams. Any medical history or diagnosis that can affect the eyes will result in the visit being billed to your MEDICAL INSURANCE.

Date of Last Eye Exam :
Primary Eye Doctor :
Date of Last Physical Exam :
Primary Care Physician :

OCCUPATION VISION CONCERNS

Do you perform extensive up-close work? :
Does your job require safety glasses? :

Are you outdoors all or much of the time?
How much time spend on a computer daily?

CURRENT EYEWEAR STATUS

Glasses Worn ?
Do you wear bifocals?
Trifocals?
Progressives (no line)?

MEDICAL/EYE HISTORY

Do you have any allergies to medications ?

If Yes,explain :
List any medications taken (including oral contraceptives, over the counter medications, and home remedies)

Do you currently have any problems in the following areas ?

Diabetes : High Blood Pressure : Heart Disease : Thyroid Disease : Asthma : Rheumatoid Arthritis : Headaches : Allergies / Hay Fever : Elevated Cholesterol : HIV :

Blurred Vision : Eye Surgery : Eye Injuries : Glaucoma : Cataract : Macular Degeneration : Floaters / Flashers : Itchy Eyes : Dry Eyes :

If you answered "yes" to any of the above or have a condition not listed, please explain

Please note any family history for the following conditions ?

Disease/Condition
Diabetes : High Blood Pressure : Glaucoma : Cataract : Macular Degeneration : Heart Disease :

If history in family,list relationship to you
Relation to you : Relation to you : Relation to you : Relation to you : Relation to you : Relation to you :

CONTACT LENS USE

Years Worn :
Soft or Rigid ? :
Do you sleep in your contacts ? :

Brand of contact lens ? :
Solution Brand:
Age of Contacts :

SOCIAL HISTORY

Do you drive ? :
Do you have visual difficulty when driving ? :

Please discribe ? :

Do you use tobacco products ? :

How much and how long ? :

Do you drink alcohol ? :

How much ? :

Call

OCCUPATION VISION CONCERNS

CURRENT EYEWEAR STATUS

MEDICAL/EYE HISTORY

Do you currently have any problems in the following areas ?

Please note any family history for the following conditions ?

CONTACT LENS USE

SOCIAL HISTORY

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