Health and Vision History Form

Please complete prior to your visit. We appreciate you helping us continue to get to know you and your eyes.

We Believe Success Starts with Your Vision

Patient Information

First Name

Middle Initial

Last Name

Date of Birth

Full Name of Primary Care Physician

Date of Last Physical Exam

Health History

If you have diabetes, please provide your most recent HA1C and blood sugare.

Are you currently receiving treatment from a physician?

Yes No

If yes, please explain:

Have you recently had any illness?

Yes No

If yes, please explain:

Do you have any double vision or difficulty focusing?

Yes No

If yes, please explain:

Are you pregnant or nursing?

Yes No

Are you taking or using any medication?

Yes No

If yes, please list medications below or bring your medication list to your appointment.

Eyewear Assessment

What features are important to you when picking out glasses? Please select your THREE most important.

Comfort/Lightness

Aesthetics/Look great on me

Brand Name/Trendy

Material/Weight/Hypo-allergenic

Made in America

Sustainability

Lowest Cost

Durability

Most Advanced Lens Technology

Contact Lens Assessment

Do you currently wear contact lenses?

Yes No

How often do you replace your contact lenses?

Do you sleep in your contact lenses?

Yes No

What brand do you wear and what cleaning solution do you use, if any?

On a scale from 1 (poor) - 10 (excellent) please rate how your contact lenses feel immediately after you put them in.

On a scale from 1 (poor) - 10 (excellent) please rate how your contact lenses feel JUST BEFORE you take them out.

Eye Comfort

Please answer the following questions by selecting the option that best represents your answer.

1. Dryness, Grittiness or Scratchiness

a. Report the type of SYMPTOMS you experience and when they occur:

At this Visit

Yes No

Within past 72 hours

Yes No

Within past 3 months

Yes No

2. Soreness or Irritation

a. Report the type of SYMPTOMS you experience and when they occur:

At this Visit

Yes No

Within past 72 hours

Yes No

Within past 3 months

Yes No

3. Burning or Watering

a. Report the type of SYMPTOMS you experience and when they occur:

At this Visit

Yes No

Within past 72 hours

Yes No

Within past 3 months

Yes No

4. Eye Fatigue

a. Report the type of SYMPTOMS you experience and when they occur:

At this Visit

Yes No

Within past 72 hours

Yes No

Within past 3 months

Yes No

Lifestyle Index

This questionnaire is meant to help you doctor understand what you are experiencing on a regular basis - whether its caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.

Number of Hours Per Day on a Digital Device

Review of Health: Are there any health problems or anything for which you being treated that we do not know about?

Please describe below. Your technician will review this information during your visit.

Your information will be encrypted.

Health and Vision History Form

Please complete prior to your visit. We appreciate you helping us continue to get to know you and your eyes.

Patient Information

Health History

Eyewear Assessment

Contact Lens Assessment

Eye Comfort

1. Dryness, Grittiness or Scratchiness

2. Soreness or Irritation

3. Burning or Watering

4. Eye Fatigue

Lifestyle Index

Review of Health: Are there any health problems or anything for which you being treated that we do not know about?

Please complete prior to your visit. We appreciate you helping us continue to get to know you and your eyes.

Northwest EyeCare Professionals