Urban Optique and Eyecare

Patient Name

First Last

Date of birth

Untitled

Ethnicity

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cellphone

Text ok?

Yes
No

Email

Hobbies:

Hours per day on computer:

When was your last eye exam:

How old are your glasses:

How old are your sunglasses:

What kind of contacts have you worn in the past?

Disposable
Toric
Hard/Gas perm
Conventional Yearly

Name of Contact Lens Brand?

When was the last time you wore your contacts?

Eye & Health History

Blurred Vision

Yes
No

Burning

Yes
No

Cataract

Yes
No

Color Blindness

Yes
No

Crossed Eyes

Yes
No

Double Vision

Yes
No

Drooping Eyelids

Yes
No

Dryness

Yes
No

Excess Tearing

Yes
No

Eye Pain

Yes
No

Floaters or spots

Yes
No

Foreign Body Sensation

Yes
No

Glare

Yes
No

Glaucoma

Yes
No

Gritty Feeling

Yes
No

Halos

Yes
No

Headaches

Yes
No

Infection, eyelid

Yes
No

Itching

Yes
No

LASIK or RK

Yes
No

Lazy Eye

Yes
No

Loss of vision

Yes
No

Macular Degeneration

Yes
No

Redness

Yes
No

Retinal Detachment

Yes
No

Tired Eyes

Yes
No

Personal Health History

Allergies

Yes
No

AIDS/HIV

Yes
No

Arthritis

Yes
No

Anxiety/Depression

Yes
No

Blood/Lymph

Yes
No

Cholesterol

Yes
No

Diabetes

Yes
No

Ears/Nose/Throat

Yes
No

Endocrine

Yes
No

Genitourinary

Yes
No

Gastrointestinal

Yes
No

Heart Trouble

Yes
No

High Blood Presure

Yes
No

Immunologic

Yes
No

Kidney

Yes
No

Muscle/Joint/Bone Pain

Yes
No

Neurological

Yes
No

Currently pregnant

Yes
No

Asthma

Yes
No

Psychiatric

Yes
No

Respiratory

Yes
No

Skin

Yes
No

Thyroid

Yes
No

Weight loss/gain

Yes
No

Epilepsy

Yes
No

Family History

Arthritis

Yes
No

Color Blindness

Yes
No

Cancer

Yes
No

Cataract

Yes
No

Diabetes

Yes
No

Glaucoma

Yes
No

Heart disease

Yes
No

High blood pressure

Yes
No

Kidney disease

Yes
No

Lazy eye

Yes
No

Lupus

Yes
No

Macular Degeneration

Yes
No

Retinal Detach

Yes
No

Stroke

Yes
No

Thyroid disease

Yes
No

Social History

Do you drink alcohol?

Yes
No

How frequently?

Do you use tobacco products?

Yes
No

How frequently?

Do you use illegal drugs?

Yes
No

How frequently?

Please list any medications you are currently taking:

Do you have a sensitivity/allergy to any medications?

Do you have a sensitivity/allergy to any non-medication substances?

Signature

Name

First Last

Date

APPOINTMENT CANCELLATION POLICY: Please Sign Initials

If you need to make a change for your appointment, please contact us within 24 hours to avoid a $25 cancellation fee.

Urban Optique & Eyecare

Eye & Health History

Personal Health History

Family History

Social History