Thomas Eye Center

Name

First Name

MI

Last Name

Title (Mr./Mrs./etc.)

Gender (M/F)

What is the major purpose of this visit?

Are there any problems with your present lenses or glasses?

Emergency Contact

Name

Phone Number

Are you a new patient?

Yes

No

Do you participate in a flex spending account?

Yes

No

How will you settle your account at time of service?

Cash

Check

Credit Card

Family Medical/Eye History

	Condition	Relationship to Patient
	Blindness
	Cataracts
	Corneal Problems
	Glaucoma
	Lazy Eye
	Macular Degeneration
	Retinal Problems
	Diabetes
	Heart Disease
	High Blood Pressure

Name of Family Physician

City, State

Date of Last Physical Check-up

/

Current Medications

List the names of the medications, prescriptions or over-the-counter including eye drops, vitamins & birth control pills

Allergies to Medications?

Yes

No

Have you ever been diagnosed or treated for the following?

Please list any surgeries you've had

Date of Last Eye Exam

/

Dilated?

Yes

No

By Whom?

Do you currently wear contact lenses?

Yes

No

Have you ever tried contact lenses?

Yes

No

Would you prefer clear contact lenses or colored lenses to change the color of your eyes?

Clear contacts

Colored lenses

Do You...

Work at a computer?

Think you might benefit from thinner, lighter lenses?

Have interest in a "Test Drive" of the latest contact lens design?

Spend time outdoors?

Have prescription sunglasses?

Prefer not to wear your glasses at times?

Have interest in a non-surgical approach to vision correction?

Have family members in need of eyecare?

If you wear bifocals, do the lines or head tilting bother you?

Yes

No

Part 1: Patient History Form

Name

What is the major purpose of this visit?

Are there any problems with your present lenses or glasses?

Emergency Contact

Are you a new patient?

Who may we thank for referring you to our office?

If not referred how did you choose our office for your needs?

Do you participate in a flex spending account?

How will you settle your account at time of service?

Family Medical/Eye History

Patient Medical History

Name of Family Physician

City, State

Date of Last Physical Check-up

Current Medications

Allergies to Medications?

Have you ever been diagnosed or treated for the following?

Please list any surgeries you've had

Patient Eye History

Date of Last Eye Exam

By Whom?

Do you currently wear contact lenses?

What kind?

Solutions used?

Are you satisfied with the vision and comfort?

Have you ever tried contact lenses?

Would you prefer clear contact lenses or colored lenses to change the color of your eyes?

Do You...

If you wear bifocals, do the lines or head tilting bother you?

Have you ever been diagnosed or treated for the following?

Do you experience or have you ever experienced?

Address

Phone/FAX

Email

Office Hours

Handicap Accessible

Directions