Ophthalmology Intake Form: What Eye Care Practices Should Collect

Ophthalmology patients range from routine vision checks to complex surgical consultations. Your intake form needs to handle both, capturing enough detail for a glaucoma evaluation without overwhelming someone who just needs an updated glasses prescription.

The key is conditional logic: a single smart form that adapts based on the patient's reason for visit.

Demographics and Contact Information

Name, date of birth, address, phone, email, emergency contact. Include referring physician (many ophthalmology patients are referred by optometrists or PCPs) and preferred pharmacy for post-visit prescriptions.

Reason for Visit

Let patients select their primary reason:

• Routine eye exam / vision check
• New eye complaint or symptom
• Follow-up on existing condition
• Surgical consultation (cataract, LASIK, etc.)
• Contact lens fitting
• Diabetic eye exam
• Glaucoma evaluation

This selection drives what additional sections appear. A routine exam patient sees a streamlined form. A surgical consultation patient sees detailed sections on surgical history and expectations.

Vision History

• When was the last eye exam? Where?
• Current corrective lenses: glasses, contacts, both, none
• For glasses: single vision, bifocal, progressive
• For contacts: type (soft, rigid, toric, multifocal), brand, wearing schedule
• Satisfaction with current vision correction
• Difficulty with near vision, distance vision, or both
• Night vision problems
• Recent changes in vision (sudden or gradual)

Current Eye Symptoms

A symptom checklist specific to ophthalmology:

• Blurry vision (near, far, or both)
• Double vision
• Eye pain or discomfort
• Redness or irritation
• Excessive tearing or dry eyes
• Light sensitivity
• Floaters or flashes
• Peripheral vision loss
• Difficulty with glare
• Eye discharge
• Itching

For any positive symptom, conditional fields should capture: which eye (left, right, both), duration, severity, and whether it's constant or intermittent.

Eye Condition History

Previous eye diagnoses and conditions:

• Glaucoma (type, treatment)
• Cataracts
• Macular degeneration (dry or wet)
• Diabetic retinopathy
• Retinal detachment or tears
• Amblyopia (lazy eye)
• Strabismus
• Corneal conditions (keratoconus, dystrophies)
• Dry eye syndrome
• Uveitis or iritis
• Eye injuries

Eye Surgery History

Patients often have several prior procedures:

• Cataract surgery (which eye, when, IOL type)
• LASIK or PRK
• Retinal surgery
• Glaucoma surgery or laser
• Eyelid surgery
• Corneal transplant
• Strabismus surgery
• Intravitreal injections (for macular degeneration or diabetic eye disease)

For each procedure, capture: date, which eye, surgeon if known, and outcome.

Family Eye History

Family history is a major risk factor:

• Glaucoma (especially in first-degree relatives)
• Macular degeneration
• Cataracts (early onset)
• Retinal detachment
• Blindness or severe vision loss
• Keratoconus

Specify the relationship (parent, sibling, grandparent) for each positive family history.

Medications

Current medications, including eye drops (many ophthalmology patients use multiple topical medications). Capture:

• Prescription eye drops (name, frequency, which eye)
• Over-the-counter eye drops
• Oral medications and supplements
• Allergies, both medication allergies and environmental (relevant for allergic eye conditions)

Medical History

Systemic conditions that affect the eyes:

• Diabetes (type 1 or 2, HbA1c if known)
• Hypertension
• Autoimmune conditions (rheumatoid arthritis, lupus, Sjogren's)
• Thyroid disease (Graves' disease)
• Migraine history
• Neurological conditions

Insurance

Vision insurance and medical insurance are separate in ophthalmology. Capture both:

• Medical insurance (carrier, member ID, group number)
• Vision insurance (carrier, member ID), if applicable
• Subscriber information for each

This distinction matters because routine exams may bill to vision insurance while medical conditions bill to medical insurance.

Consent

Consent for examination, consent for dilation (patients should know they may be dilated and need someone to drive), HIPAA privacy notice, and e-signature.

Building Your Ophthalmology Form

Conditional logic keeps this form manageable: a routine exam patient finishes quickly, and a complex glaucoma patient only sees the questions that apply.

In Formisoft, the AI builder drafts the structure and our team sets it up with you. Built-in medication and conditions fields cover the clinical sections, and separate pages keep vision history, medical history, and insurance easy to follow.

Attach the form to your visit types, and the dashboard shows which patients are ready before they arrive. See how patient readiness works.