University Vision Centre

Patient Information
Have you been examined by one of our doctors before?
- Yes
- No
Name*
First Middle Last
Nickname
Birthdate
MM slash DD slash YYYY
Gender
- Male
- Female
SSN
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Home Phone
Daytime Phone
Cell Phone
Pager
Fax
Marital Status
- Minor (under 18)
- Single
- Married
- Divorced
- Widowed
- Separated
Employer
Occupation
If you are a new patient, how were you referred to us?
- By a person
- Insurance company
- Internet search
- Phonebook/Yellowpages
- Sign/building
Who referred you, and what is your relationship?
Responsible Party
Who is the adult responsible for this account?
- Self
- Other
Name
First Last
Is this person's address the same as the yours?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Daytime Phone
SSN
Employer
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Insurance Information
Be sure to bring your insurance card(s) to your appointment.
Medical Insurance (Type and ID)
Vision Insurance (Type and ID)
Health History
How long since your last eye exam?
Name of last eye doctor.
Who is your medical doctor?
Have you had any of the following conditions?
- Cataract
- Macular Degeneration
- Glaucoma
- Eye Surgery
- High Blood Pressure
- Diabetes
Have any of your relatives had any of the following conditions?
- Cataract
- Macular Degeneration
- Glaucoma
- High Blood Pressure
- Diabetes
Social/Occupational
Do you drive?
- Yes
- No
Do you have visual difficulty when driving?
- Yes
- No
Please specify.
- Blurred distance vision (signs, etc.)
- Blurred vision at night
- Glare at night
- Dashboard is blurred
- Other
Please specify.
Do you use tobacco products?
- Yes
- No
Do you drink alcohol?
- Yes
- No
Do you use illegal drugs?
- Yes
- No
Have you ever been diagnosed with:
- Gonorrhea
- Hepatitis
- HIV
- Syphilis
- Chlamydia
- None of the above
Do you have any special visual needs?
Please list any medications you are taking.

Include aspirin, oral contraceptives, over the counter medications, home remedies, and eyedrops. If you do not know the name of the medication, please list the condition it is treating.
Review of Systems
Eyes
- None
- Eye Pain/Soreness
- Redness
- Burning
- Itching
- Watering
- Cataracts
- Glaucoma
- Macular Degeneration
- Retinal Detachment
- Dryness
- Discharge
- Strain/Tirednss
- Twitching Eyelid
- Eye Injury
- "Lazy" Eye
- "Crossed" Eye
- Blindness
- Dry Eyes
- Spots/Floaters
- Flashes
- Glare
- Double Vision
- Drooping Eyelid
- Eye Infection
- Eye Injury
- Eye Disease
- Eye Surgery
- Stye/Chalazion
- Light Sensitivity
- Distorted Vision
- Irritation/Sandy or Gritty Feeling
- Loss of Peripheral (side) Vision
- Poor Color Vision
- Eye Allergies
- Other
Check all that apply
Please specify.
Name of Surgeon(s)
Date of Surgery
MM slash DD slash YYYY
Allergic/Immunologic
- None
- Drug Allergy
- Environmental Allergy
- Rheumatoid Arthritis
- Lupus
Cardiovascular
- None
- Heart Disease
- Hypertension
- Stroke
- Vascular Disease
Respiratory
- None
- Cigarette Smoker
- Asthma
- Bronchitis
- Emphysema
Endocrine
- None
- Non-insulin dependent diabetes
- Insulin-dependent diabetes
- Thyroid dysfunction
- Hormonal dysfunction
Ears, Nose, Mouth & Throat
- None
- Upper Respiratory Tract Infection
Gastrointestinal
- None
- Crohn's
- Colitis
- Ulcer
- Digestive
Genitourinary
- None
- STD
Integumentary
- None
- Eczema
- Rosacea
- Psoriasis
Musculoskeletal
- None
- Fibromyalgia
- Muscular dystrophy
- Osteoarthritis
- Ankylosing spondylitis
Neurological
- None
- Multiple sclerosis
- Epilepsy
Psychiatric
- None
- Depression
- Panic Disorder
- Schizophrenia
Constitutional
- None
- Developmental disability
- Weight Loss
- Fever
- Fatigue
- Trauma
Other condition(s) not listed above?
Current Vision
What types of vision correction are you interested in?
- Glasses
- Contact Lenses
- Laser vision correction
- Non-surgical
Check any that apply:
- Glasses
- Contact Lenses
- Lost/Broke/Discontinued glasses
- Never had prescription glasses
Current glasses are:
- Single Vision
- Bifocals
- Trifocals
- "Invisible Bifocals"
Without lenses distance vision is:
- Clear
- Not Clear
- Not Sure
Without lenses near vision is:
- Clear
- Not Clear
- Not Sure
With current lenses distance vision is:
- Clear
- Not Clear
- Not Sure
With current lenses near vision is:
- Clear
- Not Clear
- Not Sure
I wear my glasses for:
- Distance only
- Near only
- Computer only
- Everything
Are you a past or current contact lens wearer?
- Yes
- No
Are you interested in wearing contact lenses?
- Yes
- No
When did you last wear contact lenses?
- Currently
- Less than a year ago
- More than a year ago
With contact lenses distance vision is:
- Clear
- Not Clear
- Not Sure
With contact lenses near vision is:
- Clear
- Not Clear
- Not Sure
Contact lens comfort?
- Good
- OK
- Poor
Please specify (dry, irritating, etc.)
Current Lenses are:
- Soft
- Rigid Gas Permeable
What type?
- Conventional
- Disposable
- Toric
- Bifocal
- Monovision
- Clear
- Colored
What type?
- Conventional
- Toric
- Bifocal
- Monovision
Brand/Power/Base Curve, if known:
Do you remove your lenses every night?
- Yes
- No
How many nights in a row do you sleep in your lenses (on average)?
How often do you replace your lenses? Every:
- Day
- Week
- 2 Weeks
- Month
- Year
Submitting your Form
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University Vision Centre

Patient Information

Responsible Party

Insurance Information

Health History

Social/Occupational

Review of Systems

Current Vision

Submitting your Form