Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Ophthalmology Intake Form
Eye Care Intake Form Please complete this form before your eye exam. Providing thorough information about your vision and eye health history helps us deliver the most effective care.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Vision & Eye Health History Please describe your current vision concerns and any relevant eye health history.
Reason for Visit *
Date of Last Eye Exam
____ / ____ / ________
Do You Wear Glasses or Contact Lenses? *
- Glasses
- Contact Lenses
- Both
- Neither
Current Vision Complaints
- Blurred Vision
- Double Vision
- Eye Pain
- Redness
- Dryness
- Floaters
- Light Sensitivity
- Night Vision Problems
- None
Eye Conditions
- Glaucoma
- Cataracts
- Macular Degeneration
- Diabetic Retinopathy
- Lazy Eye
- None
Eye Surgery History
Family Eye History
- Glaucoma
- Cataracts
- Macular Degeneration
- Blindness
- None
Current Medications
Medical Conditions
- Diabetes
- High Blood Pressure
- Autoimmune Disease
- Thyroid Disease
- None
Drug Allergies
Ophthalmology Intake Form template from formisoft.com. formisoft.com/intake-templates/ophthalmology-intake