Adult Questionnaire

Adult Questionnaire
Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home phone number

- Area Code Phone Number
Cell phone number

- Area Code Phone Number
Work phone number

- Area Code Phone Number
Date of birth:
E-mail
Insurance provider
Insurance ID #
Primary Insured Name:
Primary insured date of birth:
Are you the primary?

Yes No
If you answered No, please give us the name of date of birth of the primary:
Occupation:
Place of work:
Referred by:
May we add you on Facebook?

Yes No
If yes, what is your contact 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 vision Headaches Difficulty in depth perception Burning of eyes Itchy eyes Difficulty with driving Tearing/watery eyes Light sensitivity Poor sports performance Redness of the eyes Double vision Tired or sleepy doing visual tasks Short attention span Slow reading Loss of place while reading Back or neck pain Low reading comprehension Eye(s) turn: in, out, up, down Visual discomfort with computer work Clumsiness/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:
Eye Doctor's 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? When?
Doctor's name and address:
Have you ever had an eye patched? If so, when?
Detail any history of eye disease or surgery:
Do you ever see bright flashes of light or floating spots?
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 pressure Diabetes Arthritis Cancer Allergies/Asthma Heart disease Glaucoma Cataracts
Other:
List any medications you are currently using:
Do you have any allergies?
Name of your physician:
Address:
May we send a report of our findings to your physician?

Yes No
Is there any family history of:

High blood pressure Diabetes Glaucoma Macular degeneration Retinal detachment Other eye disease
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Adult Questionnaire

Vision History

Contact Lenses History

Medical History