Patient Intake Form

Patient Intake Form

Please complete this form prior to your appointment at Ancala Eye Care.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Address

CityState / ProvincePostal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
Occupation / Retired
What are your Hobbies / Interests? How do you use your eyes? How many hours per day do you work on a computer?
Reason for today's visit
Do you have a medical history of (check all that apply):

Other
Does your family have a medical history of (check all that apply):

Other
Do you have a history of (check all that apply):

Other
Does your family have a history of (check all that apply):

Other
Have you had eye surgery?
What year did you have surgery?
Height
Weight
What is your blood pressure?
Are you a smoker?
Approximately, when was your last eye exam?

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Name of Eye Doctor
Primary Care Physician
Do you have any allergies?
Please list your allergies (seasonal, medications, etc)
List any medications you are currently taking (include prescriptions, over-the-counter meds, vitamins, nasal sprays, and birth control).
Do you wear glasses?
What kind?
Do you wear contact lenses?
Please make sure to bring in your contact lens information including the lens type and brand. The box the contacts come in is ideal. Do you agree to come prepared with this information?
Is there anyone we can provide your medical information to?
What is their name?
Relationship
Their Phone Number
Format: (000) 000-0000.
Additional comments or information
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: