Savitt's Optometry

Intake Form

Please correct the errors described below.

Client Information

Date

Title

First name

Middle Initial

Last name

Address

City

State

Zip Code

Phone Number Preference

Landline

Cell Phone

Phone Number

Email address

Date of birth

Last 4 Digits of Social Security Number

Marital Status

Occupation

Employer / School

How did you hear about us?

Online Search

Social Media

Family/Friend Referral

Insurance Provider

Whom may we thank for referring you?

Is the patient a minor?

Yes No

Mother's Information

Are you able to provide the mother's information?

Yes

No

First Name

Last Name

Adress

City

State

Zip Code

Phone Number

Last 4 Digits of Social Security Number

Date of Birth

Employer

Father's Information

Are you able to provide the father's information?

Yes

No

First Name

Last Name

Adress

City

State

Zip Code

Phone Number

Last 4 Digits of Social Security Number

Date of Birth

Employer

Insurance Information

Vision Insurance

Other:

Subscriber Name

Subscriber Date of Birth

Medical Insurance

Subscriber Name

Subscriber Date of Birth

Eye and Vision Information

Is there a specific reason you decided to get your eyes checked?

Yes No

If yes, please describe the reason for your visit

Date of your last eye exam

Previous Eye Doctor

Were you dilated?

Yes No

Do you wear glasses?

Yes No

Do you wear contact lenses?

Yes No

What type of contact lenses do you wear?

Are you interested in laser vision correction?

Yes No Maybe

Do you currently experience any of the following?

Blur at a Distance

Blur at Near

Trouble Seeing at Night

Trouble with Glare

Distortion

Light Bothers Eyes

See Floaters or Flashes

Eye Pain/Ache

Eyes Water

Eyes Burn/Dry

Eyes Red

Eyes Discharge

See Double

Frequent Headaches

None of the above

Do you have or had in the past...

Eye Surgery

Eye Injury, Abrasion, Foreign Body

Turned, Crossed, or Lazy Eye

Glaucoma

Cataracts

Other Eye Problem

None of the above

For

Other

Do you use eye drops?

Yes No

List the eyedrops you currently use:

Medical Information

Who is your healthcare physician?

Address of your healthcare physician:

Do you have or ever had any problems with any of the following systems (common conditions are given in parenthesis)? Please select yes or no; list your specific condition(s), and list all medications in the space provided.

Constitutional (Fever, Weight Loss/Gain)

Yes No

Specific condition and all related medications:

Integumentary (Skin Conditions, Acne, Rosacea)

Yes No

Specific condition and all related medications:

Neurological (Seizures, Headache, Migraines)

Yes No

Specific condition and all related medications:

Endocrine (Thyroid, Diabetes)

Yes No

Specific condition and all related medications:

Ears, Nose, Throat (Sinus, Cough)

Yes No

Specific condition and all related medications:

Respiratory (Asthma, Bronchitis)

Yes No

Specific condition and all related medications:

Cardiovascular (Blood Pressure, Cholesterol, Heart, Stroke)

Yes No

Specific condition and all related medications:

Gastrointestinal (Diarrhea, Constipation, Acid Reflux)

Yes No

Specific condition and all related medications:

Genitourinary (STD's, Birth Control, Kidney, Bladder)

Yes No

Specific condition and all related medications:

Musculoskeletal (Arthritis, Fibromyalgia)

Yes No

Specific condition and all related medications:

Lymphatic (Anemia, Leukemia, Keyloid Scarring)

Yes No

Specific condition and all related medications:

Allergic (List All Known Allergies or Hay Fever)

Yes No

Specific condition and all related medications:

Immunologic (HIV)

Yes No

Specific condition and all related medications:

Psychiatric (Depression, Anxiety)

Yes No

Specific condition and all related medications:

Tobacco, Alcohol, or Illegal Drug Use

Yes No

Specific condition and all related medications:

Please list any other health conditions and all medications in the space below:

Are you allergic to any medications?

Yes No

List medications and your reactions:

Family History

Does anyone in your family have any of the following conditions? State their relation to you.

Glaucoma

Yes No

Their relation to you:

Cataracts

Yes No

Their relation to you:

Blindness/Muscular Degeneration

Yes No

Their relation to you:

Corneal Problems

Yes No

Their relation to you:

Turned, Crossed, or Lazy Eye

Yes No

Their relation to you:

Retinal Problems

Yes No

Their relation to you:

Diabetes

Yes No

Their relation to you:

High Blood Pressure

Yes No

Their relation to you:

I certify that this information is accurate to the best of my knowledge:

Type your first and last name

Today's Date

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Savitt's Optometry

Providing Cleveland, Ohio with comprehensive eye examinations, contact lenses, treatment of eye infections, diseases & more! We are excited to provide you with professional eye care services in a comfortable and friendly environment. Our practice is a local, family-owned office committed to offering top-notch services with advanced technology. Please contact us to schedule your appointment today.

440-943-1993
savittsoptometry.com
sidsavitt
savitts_optometry
29610 Euclid Ave , Wickliffe, Ohio, 44092, United States

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