Patient Information
Full Name Address Zip Code City Gender Birthday (MM/DD/YYYY) Language Phone Number Email Country

General Information
Date of Last Eye Exam (MM/DD/YYYY) Name of Eye Doctor Do you wear glasses? Do you see clearly with your current RX? Have you been diagnosed with an eye disease? Have you ever had eye surgery? Do you use eye drops Have you ever worn contact lens?

Health Information
Date of your last physical exam Name of Primary Care Physician Do you currently take any medications? Do you have any allergies to drugs? Do you have any environmental allergies? Have you had any surgical procedures on your EYES?

Current Symptoms
*Please check all that apply

Dry, itchy, tearing or burning eyes
Foreign body sensation in eyes
Pain in or around the eyes
New/sudden onset of double vision
Red Eyes
Headaches
New or sudden onset of floaters
New flashes of lights

Green/Yellow/Brown discharge from eyes

Do your eyelashes stick together?
Do you smoke?
Do you drink?