Optometry Contact Lens Fitting Intake Form
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Optometry Contact Lens Fitting Intake Form
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This comprehensive contact lens fitting intake form is designed specifically for optometrists and optical practices performing contact lens evaluations, fittings, and follow-up care. The form systematically collects critical information including current lens wearing history, previous fitting challenges, ocular health concerns, daily wearing schedules, and lifestyle activities that impact lens selection. It captures detailed refractive history, corneal health indicators, tear film quality, and any history of complications such as infections, allergies, or discomfort.
The form facilitates efficient patient evaluation by documenting lens preferences for daily disposables versus extended wear, color preferences, astigmatism correction needs, and presbyopia considerations for multifocal options. It includes sections for occupational visual demands, screen time exposure, environmental factors like air conditioning or dusty conditions, and cosmetic goals. This structured approach helps practitioners select the most appropriate lens material, replacement schedule, and care system while ensuring proper patient education on insertion, removal, hygiene protocols, and compliance with wearing schedules for optimal ocular health outcomes.
What's included
- Current contact lens wearing status and history
- Brand, type, and prescription of existing lenses
- Daily wearing schedule and overnight wear habits
- Lens care solution and hygiene practices
- History of complications, infections, or allergies
- Dry eye symptoms and tear film quality
- Lifestyle factors affecting lens selection
- Occupational and recreational visual needs
- Corneal health and previous fitting challenges
- Patient preferences for lens type and replacement schedule
Who uses this template
- Optometry clinics offering contact lens services
- Optical retail practices with in-house optometrists
- Vision care centers specializing in specialty lens fittings
- Ophthalmology practices with contact lens departments
- Pediatric optometry offices fitting children and teens
All form fields
10 fields across 3 pages. Customize any field after signing up.
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