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Ophthalmology Intake Form
Intake

Ophthalmology Intake Form

2 pages•12 fields•HIPAA-ready
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Ophthalmology Intake Form
Patient Information
Phone Number
Email Address
Current Vision Symptoms
Glasses/Contact Lens Prescription
Previous Eye Surgeries
Family Eye Disease History
Screen Time & Occupational Use
Select...
Eye Medications (Drops/Ointments)
Dry Eye Symptoms
General Medical History
Diabetes
Hypertension
Asthma
Heart Disease
Consent to Examination
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The Ophthalmology Intake Form serves ophthalmologists, optometrists, and vision care clinics. It captures comprehensive eye health information: current vision symptoms, vision correction history (glasses and contact lens prescriptions), previous eye surgeries and procedures, eye disease family history, and occupational vision demands.

The symptom section is tailored for eye care with specific questions about blurred vision, floaters, flashes, double vision, eye pain, dryness, and light sensitivity. These detailed symptom descriptors help the provider focus the examination and anticipate potential diagnoses.

Family eye disease history covers glaucoma, macular degeneration, cataracts, retinal detachment, and other hereditary conditions. The occupational section captures screen time, driving requirements, and specialized vision needs that inform prescription decisions. This template also works well for pre-operative evaluations for LASIK, cataract surgery, and other eye procedures.

What's included

  • Vision symptom checklist (floaters, flashes, blur)
  • Glasses and contact lens prescription history
  • Eye surgery and procedure history
  • Family eye disease screening
  • Occupational vision demands assessment
  • Eye medication documentation
  • Medical conditions checklist
  • E-signature capture
  • Structured medication list with dosage and frequency tracking

Who uses this template

  • Ophthalmology practices
  • Optometry offices and vision clinics
  • LASIK and refractive surgery centers
  • Retina and glaucoma specialty clinics

All form fields

12 fields across 2 pages. Customize any field after signing up.

Patient InformationText
Phone NumberPhone
Email AddressEmail
Current Vision SymptomsCheckbox
Glasses/Contact Lens PrescriptionText
Previous Eye SurgeriesCheckbox
Family Eye Disease HistoryCheckbox
Screen Time & Occupational UseDropdown
Eye Medications (Drops/Ointments)Medications
Dry Eye SymptomsMultiple Choice
General Medical HistoryConditions
Consent to ExaminationE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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