Adult Questionnaire

Adult Questionnaire
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home phone number

Area CodePhone Number
Cell phone number

Area CodePhone Number
Work phone number

Area CodePhone Number
Date of birth:
E-mail
Insurance provider
Insurance ID #
Primary insured name:
Primary insured date of birth:
Are you the primary?

YesNo
If you answered no, please give us the name and date of birth of the primary:
Occupation:
Place of work:
Referred by:

First NameLast Name
May we add you on Facebook?

YesNo
If yes, what is your contact name?

First NameLast Name
What is your main problem or concern?
How long has this problem been noted?
Are you presently experiencing any of the following? (check all that apply)

Blurred visionHeadachesDifficulty in depth perceptionBurning of eyesItchy eyesDifficulty with drivingTearing/watery eyesLight sensitivityPoor sports performanceRedness of the eyesDouble visionTired or sleepy doing visual tasksShort attention spanSlow readingLoss of place while readingBack or neck painLow reading comprehensionEye(s) turn: in, out, up, downVisual discomfort with computer workClumsiness/bumping into things
Other
Are there any special demands you have at work or at home?
Are there any hobbies or recreational activities with special visual demands?
Vision History
Date of your last vision or eye exam:

MonthDayYear
Date
Eye Doctor's name:

First NameLast Name
Eye Doctor's address:
Diagnoses and recommendations:
Were glasses prescribed?
If so, do you wear them now?
What do you wear the glasses for?
Have you ever been involved in vision therapy? If yes, when?
Doctor's name:

First NameLast Name
Have you ever had an eye patched? If yes, when?
Detail any history of eye disease or surgery:
Do you ever see bright flashes of light or floating spots? If yes, when?
Have you ever had an injury to your eye or eyes? If so, please explain:
Have you ever suffered a head or brain injury? If so, please explain:
Contact Lenses History
Do you wear contact lenses?
Soft or RGP?
If not, are you interested?
When did you start wearing contact lenses?
Type and brand of contact lenses?
How many hours per day:
How many hours per week:
Medical History
Check all that apply:

High blood pressureDiabetesArthritisCancerAllergies/AsthmaHeart diseaseGlaucomaCataracts
Other:
List any medications you are currently using:
Do you have any allergies?
Name of your physician:

First NameLast Name
Address:
May we send a report of our findings to your physician?

YesNo
Is there any family history of:

High blood pressureDiabetesGlaucomaMacular degenerationRetinal detachmentOther eye disease
Should be Empty:

Adult Questionnaire

Vision History

Contact Lenses History

Medical History