Vision
History Questionnaire
Patient's Name:
Patient Date of Birth:
Phone number
Occupation:
Date of Last Eye Exam:
Do you wear glasses?
Yes
No
If yes, how old is your present pair of glasses?
Do you wear contact lenses?
Yes
No
If yes, how old is your present pair of lenses?
Type of contact lenses:
Rigid
Soft
Extended Wear
Other:
Are they comfotable?
Yes
No
Do you use eyedrop
s?
Yes
No
If yes, please list name of drops.
Are you pregnant or nursing?
Yes
No
Have you had any eye injury?
Yes
No
If yes, please list any type of eye injury you have had.
Have you had any eye surgeries?
Yes
No
If yes, please list any eye surgeries you have had.
Check any of the following you have had:
Crossed Eyes
Drooping Eyelid
Glaucoma
Cataracts
Lazy Eye
Prominent Eyes
Retinal Disease
Eye Infections
Do you Drive?
Yes
No
If you drive do you have visual difficulty when driving?
Yes
No
If you have visual difficulty when driving, please describe.
Family History
Please mark any family history for the following (living or deceased) for the following conditions:
Blindness
Child
Mom
Dad
Grandparent
Siblings
Crossed Eyes
Child
Mom
Dad
Grandparent
Siblings
Diabetes
Child
Mom
Dad
Grandparent
Siblings
Glaucoma
Child
Mom
Dad
Grandparent
Siblings
Macular Degeneration
Child
Mom
Dad
Grandparent
Siblings
Retinal Detachment/Disease
Child
Mom
Dad
Grandparent
Siblings
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