Eye Associates
Secure Form
How did you hear about us?
Friend/Relative
Another Healthcare Provider
Internet
Event/Other
General Information
Patient Name
First
Last
Date of birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
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
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Gender
Male
Female
SSN
Home Phone
Work Phone
Cell Phone
Preferred Phone
Home Phone
Work Phone
Cell Phone
Email
Race
Caucasian
African American / Black
Hispanic / Latino
Asian
Native American
Hawaiian
African
Arab
Multiracial / Other
Ethnicity
Hispanic / Latino
Not Hispanic / Latino
Native / Preferred Language
Employer (or School)
Occupation (or Grade)
Emergency Information
Contact Name
Contact Phone
Spouse (If Married)
Parent (If Child)
Health History
Last Eye Exam
MM slash DD slash YYYY
Last Eye Exam Doctor / Location
Do you wear contacts?
Yes
No
Contacts Type
Do you wear glasses?
Yes
No
How old are they?
Have you been experiencing any of the following?
Blurred Vision
Dry Eyes
Flashes
Redness
Floaters
Tired / Strained Eyes
Light Sensitivity
Itching
Burning / Sandy Feeling
Watery Eyes
Check all that apply
Are you interested in:
Contact Lenses
Lasik
Computer Glasses
Sports Glasses
Sunglasses
Any specific visual / eyewear needs for your work or hobbies?
How long do you work at a computer per day?
Current Medications
Include over-the-counter, eye drops / meds, vitamins, oral contraceptives)
Have you experienced or been diagnosed or treated for: (If yes, check box and explain below)
Eyes
Cataracts
Glaucoma
Macular Degeneration
Dry Eye Syndrome
Retinal Tear / Detatchment
Lazy Eye
Eye Injury
Eye Surgery / Lasik
Constitutional
Developmental Disability
Cancer
Ear / Nose / Throat
Hear Loss
Sinusitis
Neurological
Multiple Sclerosis
Stroke
Migraines
Concussion
Psychiatric
Depression
Anxiety Disorder
Bipolar Disorder
Cardiovascular
High Blood Pressure
Heart Disease
Vascular Disease
Respiratory
Asthma
COPD
Sleep Apnea
Gastrointestinal
Crohn's, Colitis
Genitourinal
Kidney Disease
Sexually Transmitted Disease
Muskulosceletal
Osteoarthritis
Skin
Rosacea
Eczema / Psoriasis
Endocrine
Diabetes
Thyroid Dysfunction
Hematologic / Lymphatic
Anemia
High Cholesterol
Allergy / Immunologic
Rheumatoid Arthritis
Lupus
Other
Please Explain the selected above:
Primary Physician Information
Physician's Name
Clinic / Location
Last Exam
MM slash DD slash YYYY
Are you currently, or is there a possibility that you may be, pregnant or nursing?
Yes
No
Height
Weight
Are you allergic to any medications?
Yes
No
List allergies:
Do you have any environmental allergies / hay fever?
Yes
No
List environmental allergies:
Social History
Do you use any tobacco products?
Yes
No
How often?
Have you ever smoked?
Yes
No
Do you drink alcohol?
Yes
No
How often?
Is there a family history of any of the following?
Glaucoma
Macular Degeneration
Cataracts
Lazy Eye
Type II Diabetes
Type I Diabetes
Hypertension
Cancer
Hypothyroid
Hyperthyroid
Other Eye Disease
Explain Relationship