Welcome to The Eye Studio
Full Name
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First Name
Last Name
Guardian Name (if applicable)
First Name
Last Name
Preferred Phone Number
*
-
Area Code
Phone Number
Phone Label
*
Cell
Home
Work
Other
Alternate Phone Number
-
Area Code
Phone Number
Phone Label
Cell
Home
Work
Other
Is this your first visit to our office?
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Yes
No
Who can we thank for referring you to our practice?
If not referred, how did you hear about our practice?
Family Doctor
Internet Search
Social Media
Radio
Newspaper
Location
Direct Mail
Other
Who is your family doctor?
What is your occupation?
What is the main purpose for your upcoming appointment?
*
Are there any other concerns you would like addressed at your upcoming appointment?
Ocular History
When was your last eye exam?
Please check any symptoms that you are currently experiencing:
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Headaches
Glare / Light Sensitivity
Tired Eyes
Eye Pain / Soreness
Burning Eyes
Dry Eyes
Watery Eyes
Itchy Eyes
Redness
Distance Vision Issues
Near Vision Issues
Fluctuating Vision
Double Vision
Loss of Vision
Floaters or Spots
None of the Above
Other
Check the conditions that apply to yourself:
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Cataracts
Glaucoma
Macular Degeneration
Dry Eyes
Amblyopia (Lazy Eye)
Strabismus (Eye Turn)
None of the Above
Other
Have you ever had any eye surgeries or procedures?
Yes
No
Please give us details:
Check the conditions that are in your family history:
*
Cataracts
Glaucoma
Macular Degeneration
Dry Eyes
Amblyopia (Lazy Eye)
Strabismus (Eye Turn)
None of the Above
Other
Medical History
Check the conditions that apply to yourself:
*
Asthma
Arthritis
Cancer
Cardiac disease
Diabetes
High Cholesterol
Hypertension
Seasonal / Environmental Allergies
Epilepsy
Migraines
Sleep Apnea
Raynaud Syndrome
Psychiatric disorder
None of the Above
Other
Check the conditions that are in your family's history:
*
Asthma
Arthritis
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Migraines
Sleep Apnea
Raynaud Syndrome
None of the Above
Other
Are you currently taking any medication?
*
Yes
No
Please list your Current Medications or choose the option to upload:
Upload Your Current Medication List:
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Do you have any medical allergies?
*
Yes
No
Not Sure
Allergies:
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Contact Lens History
Do you currently wear contact lenses?
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Yes
No
When did you start wearing contacts?
What type of contacts lenses do you wear?
Daily Disposable
Monthly Disposable
RGP / Hard Contact Lenses
Scleral Conacts
On average, how many days a week do you wear your contacts?
On average, how many hours a day do you wear your contacts?
A few hours or less
5-10 hours
11-14
More than 14
Extended -Sleep in Contacts
Other
What contact lens solution do you use?
What would you like to improve about your current contacts?
Have you ever tried contacts?
Yes
No
Are you interested in trying contacts?
Yes
No
Why did you stop wearing contacts?
Are you interested in trying contacts again?
Yes
No
Vision History
Do you(r) . . . . (Check the box if the answer is yes)
eyes bother you with near tasks?
get frequent headaches with visual tasks?
have any reading or learning problems at school?
experience fatigue at the end of the school / work day?
Do you spend more than a few hours per day on a computer or screen?
Yes
No
Do you have any hobbies, sports or other interests that use your eyes in a special way?
Is there anything else that you feel is important that we know?
Submit
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