Adult Questionnaire
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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 and date of birth of the primary:
Occupation:
Place of work:
Referred by:
First Name
Last Name
May we add you on Facebook?
Yes
No
If yes, what is your contact name?
First Name
Last 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:
-
Month
-
Day
Year
Date
Eye Doctor's name:
First Name
Last 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 Name
Last 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 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:
First Name
Last Name
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
Submit
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