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

Ophthalmology patients often have multiple 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 in ophthalmology:

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

Formisoft handles ophthalmology intake well because the conditional logic keeps the form length manageable. A routine exam patient breezes through in 5 minutes. A complex glaucoma patient with surgical history takes longer, but only sees questions relevant to their situation.

Use the AI builder to generate the structure, then fine-tune with the drag-and-drop canvas. The built-in medication and conditions fields handle the clinical sections, and multi-page layout separates vision history, medical history, and insurance into digestible sections.

Try Formisoft free and build your ophthalmology intake form.