| Date: |
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| First Name: |
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| Last Name: |
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| Middle Name: |
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| Occupation: |
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| Employer: |
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| Date of Birth: |
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| Age: |
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| What frustrations do you currently have that relate to not being able to see as well as you like? |
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| List three or four of the reasons why you are now considering a vision correction procedure? |
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| Please share with us some of the physical activities that you hope to further participate in after your procedure? |
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| What activities will you be able to more fully participate in after your vision is corrected? |
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| What restrictions do you have now because of your use of contacts or glasses? |
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| Glasses History |
| 1. How often do you wear eyeglasses or contact lenses for distance vision? |
| Not All Part-time Full-time |
| 2. Do you need eyeglasses for reading? |
| Yes No |
| Contact Lens History |
| 3. Do you currently wear contact lenses? (if no, skip to 8) |
| Yes No |
| 4. What kind of contact lenses do you wear now? |
| Soft Rigid gas permeable Hard |
| 5. How long have your contacts been out? |
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| 6. Have you tried monovision with contacts (one eye for distance vision, the other eye for reading)? |
| Yes No |
| 7. If so, was it successful for you? |
| Yes No |
| Ocular History |
| 8. List all eye surgeries you have had. Indicate which eye and the date of surgery: |
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| 9. List all other surgeries you have had, with dates: |
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| 10. List eye injuries with dates: |
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| 11. List any eye diseases you have: |
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| General Medical History |
12. Do you now or did you in the past have any of the following conditions?
Please Specify |
| Atopic disease |
Yes No |
| Rheumatoid arthritis |
Yes No |
| Autoimmune Disease |
Yes No |
| Diabetes |
Yes No |
| Hepatitis |
Yes No |
| HIV infection |
Yes No |
| Keloid formation |
Yes No |
| Other medical problems |
Yes No |
| 13. List all eye drops you use, which eye, and how often you use them: |
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| 14. List all other medications you take with dosage and frequency: |
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| 15. List any medications you are allergic to: |
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| 16. If female, are you or might you be pregnant? |
| Yes No |
| 17. If female, are you trying to become pregnant? |
| Yes No |
Family Medical History |
| 18. List any eye diseases that run in your family: |
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| 19. Have you visited our website? |
| Yes No |
| 20. What led you to make an appointment with us? |
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| 21. If you were referred to us, who referred you? |
| Doctor |
(Name) |
| Friend/Family |
(Name) |
| |
Is this person a patient of ours? |
| |
Yes No |
| Address: |
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| City: |
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| State: |
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| Phone: |
( ) |
| 22. If no one referred you, do you want us to send a letter to your local eye doctor or medical doctor? |
| Yes No |
| 23. EYE DOCTOR |
| Name: |
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OPTOMETRIST/OPHTHALMOLOGIST |
| Phone: |
( ) |
| Address: |
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| 24. MEDICAL DOCTOR |
| Name: |
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| Phone: |
( ) |
| Address: |
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