Personal Information
 Eye Health History Information
Physician's Name
Name
Date of last visit
Age
Address
Date of last Eye Exam
Eye doctor's Name
Do you wear glasses?
Birthdate
Do you wear Contacts?
E-mail
Last four digits of
your Social Security
Number
Please check all that are applicable:
Bloodshot Eyes

Blurred Vision - Distance

Blurred Vision - Near

Burning Eyes

Cataracts

Color Vision, Poor

Crossed Eyes

Discharge from Eyes

Dizzy Spells

Double Vision

Dry Eyes

Eye Infection

Eye Injury

Eye Strain

Fainting Spells, Blackouts
 Floaters or Spots

Glaucoma

Headaches

Itching Eyes

Light Sensitive

Loss of Vision

Migraine Headaches

Night Vision, Poor

Red Eyes

Seeing Halos

Seeing Flashes

Temporary Loss of Vision

Twitching Eyelid

Vision Poor

Watering Eyes
Spouse's Information:
Last four digits of
your spouse's SSN
Phone Numbers:
Emergency Contact Information:
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely
as you can. If you have questions we will be glad to help you in any way we can. If you are
uncomfortable filling this information out online, a similar paper form will be provided at your time of visit.