Wufoo

Name Title First Last Suffix
Today's Date MM / DD / YYYY
Date of Birth MM / DD / YYYY
Social Security Number
Last Eye Exam MM / DD / YYYY
Address
Home Phone Number ### - ### - ####
Work Phone Number ### - ### - ####
Occupation
Last Eye Doctor
Last Medical Exam
Current Medical Doctor
Medical History
Do you have any allergies to medications?
Yes No
If yes, explain:
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies
List all major injuries, surgeries and/or hospitalizations you have had
Check Any of the following that you have had
crossed eyes lazy eye glaucoma retinal disease cataracts eye injury
Are you pregnant and/or nursing?
Yes No
Do you wear glasses?
Yes No
If yes, how old is you present pair of lenses?
Do you wear contact lenses?
Yes No
If yes, how old is you present pair of lenses?
Type of contact lenses
Rigid Soft Extended Wear Other
Are they comfortable?
Yes No
Have you had refractive surgery?
Yes No
Family History

A description of the section goes here.

Other
How did you first hear about us?
I was referred here by:
Through my insurance, which is:
I found you myself, here's how:
(Check All That Apply) At any point in your decision making process, did you:
Visit our web site Visit our Facebook page Search for us on your insurance web site Search for us on Google (or Yahoo/Bing) Visit our Yelp page Read any online reviews about us
Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I would prefer to discuss my Social History information directly with my doctor
Do you drive?
Yes No
If yes, do you have visual difficulty when driving?
Yes No
If yes, please describe:
Do you use tobacco products?
Yes No
If yes, type/amount/how long:
Do you drink alcohol?
Yes No
If yes, type/amount/how long:
Do you use illegal drugs?
Yes No
If yes, type/amount/how long:
Have you ever been exposed to or infected with:
Gonorrhea Hepatitis HIV Syphilis
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