Adult New Patient Form

Please complete this form as it lets us know the history and current state of your health. Please be as thorough as you can so we can be sure and get all the information to help solve your vision needs.

Please complete the form below or click here to download a printable version.

"*" indicates required fields

Step 1 of 5

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Your Full Name*

Date of Birth*

MM slash DD slash YYYY

Age Now*

Referred By

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Business Phone

Cell Phone

Occupation

Email*

Do you currently attend school?*

Yes

Name of School*

Current grade/level

Did you like school?*

Yes

Was a grade repeated?*

Yes

Which grade?*

Describe your school work*

Average

Better than average

Below average

Do you play sports?*

Yes

Type of sport and amount*

Other forms of exercise

Do you have any hobbies?

How do you like to spend your free time?

How many hours per day do you do the following?

Use a computer*

Read*

Watch TV*

Play Video Games*

Do you wear contact lenses at this time?*

Yes

What type?*

Have you had problems wearing contacts?*

Yes

Describe*

Are there any activities you would enjoy doing, but must restrict because of your vision?

Does your job include using a computer?*

Yes

Hours per day*

Present Situation

In what ways are you having visual difficulty?

How long has your difficulty been noticed?

Previous Visual Examinations

Reason for Exam

Date of Exam

Doctor's Name

Results

Reason for Exam 2

Date of Exam 2

Doctor's Name 2

Results 2

Reason for Exam 3

Date of Exam 3

Doctor's Name 3

Results 3

Has anyone noticed an eye turn in or wander out?*

Yes

Which eye?*

Left

Right

Both

Do you ever experience:

Headaches*

Yes

When?*

Blurred Vision Far*

Yes

When?*

Blurred Vision Near*

Yes

When?*

Double Vision*

Yes

When?*

Eyes hurt or tired*

Yes

When?*

Eye Surgery*

Yes

When?*

Have you ever noticed the following:

Holding Reading Close*

Yes

When?*

Holding Reading Further Away*

Yes

When?*

Closing One Eye?*

Yes

When?*

Covering One Eye?*

Yes

When?*

Eyes frequently reddened?*

Yes

When?*

Frequent styes?*

Yes

When?*

Excessive eye rubbing?*

Yes

When?*

Get lost in book? Unaware peripherally?*

Yes

When?*

Tilting head when reading?*

Yes

When?*

Bothered by light?*

Yes

When?*

Inability to see distant objects?*

Yes

When?*

Bumping into objects?*

Yes

When?*

Poor general coordination?*

Yes

When?*

Have you had any eye surgeries?*

Yes

When?*

Have you ever had vision therapy?*

Yes

When?*

Have you ever injured your eyes?*

Yes

When?*

Health History

Please check the conditions that apply to you or that run in your family.

Systemic Disease/Condition

Arthritis*

Yes

Relationship*

Diabetes*

Yes

Relationship*

Rheumatoid Arthritis*

Yes

Relationship*

Fever*

Yes

Relationship*

Weight loss/gain*

Yes

Relationship*

Cancer*

Yes

Relationship*

Stroke*

Yes

Relationship*

Drug Sensitive*

Yes

Relationship*

Elevated Cholesterol*

Yes

Relationship*

Heart problem/disease*

Yes

Relationship*

High blood pressure*

Yes

Relationship*

Thyroid*

Yes

Relationship*

Migraine or Headaches*

Yes

Relationship*

How often?*

Gastrointestinal*

Yes

Relationship*

Urogenital (kidney, bladder)*

Yes

Relationship*

Neurological (MS, seizures)*

Yes

Relationship*

Psychiatric (depression, etc.)*

Yes

Relationship*

Allergies*

Yes

Relationship*

Respiratory (asthma, bronchitis, emphysema)*

Yes

Relationship*

Other

Ocular Disease/Condition

Lazy eye*

Yes

Relationship*

Turned eye*

Yes

Relationship*

Color blind*

Yes

Relationship*

Light sensitive*

Yes

Relationship*

Eye strain*

Yes

Relationship*

Dry eyes*

Yes

Relationship*

Floaters/spots*

Yes

Relationship*

Flashing lights*

Yes

Relationship*

Retinal detachment or retinal disease*

Yes

Relationship*

Blindness*

Yes

Relationship*

Macular Degeneration*

Yes

Relationship*

Cataracts*

Yes

Relationship*

Crossed eyes*

Yes

Relationship*

Glaucoma*

Yes

Relationship*

Head trauma*

Yes

Relationship*

Eye surgery*

Yes

Relationship*

Please list any other pertinent health information here:

Date of your last physical

How is your general health?*

Excellent

Good

Fair

Poor

Are you currently under a doctor's care?*

Yes

Doctor's Name*

Reason

Are you taking any medications regularly?*

Yes

What medications?*

List any major illnesses, with age and severity.

As you complete this history questionnaire you will recognize the thoroughness with which your problem will be considered. The office examination will take up enough time to permit a very complete optometric investigation of any problem. I am looking forward to meeting you and helping you meet your visual needs. In order for us to keep costs down, payment is expected in full at the time of service. We do not accept assignment from insurance companies. All payments are between the patient and our office.

Consent*

I authorize the release of medical and/or other information pertinent to my care to the Southeastern Indiana Vision Development Center to help facilitate proper care.

Name*

Date*

12386