Patient Questionnaire

General Information — Red indicates a required field.
Name    
Address City
State Zip Code
Phone (Day) Phone (Eve)
Email Fax
Current Eye Doctor Occupation
Emergency Contact Phone
Date of Birth (dd/mm/yyyy) Age
Sex
Male Female
   
 
Past Medical History
1. Do you have any allergies to medications? Yes No
If yes, please list
Please use a comma ( , ) to separate multiple allergies.
2. Do you take any medications (including steroids)? Yes No
If yes, please list:
Please use a comma ( , ) to separate multiple medications.
3. Do you have any health problems? Yes No
If yes, please list:
Please use a comma ( , ) to separate multiple entries.
4. Specifically, do you have a history of:
Arthritis Yes No
Diabetes Yes No
Heart problems with pacemaker Yes No
High Blood Pressure Yes No
5. Are you pregnant or breast feeding? Yes No
 
Past Ocular History
Do you have a history of:
Glaucoma Yes No
Eye disease Yes No
Eye injury Yes No
Lazy eye/turned eye Yes No
Retinal tear or detachment Yes No
Previous Eye Surgery
None
Lasik
PRK
RK
Other
If yes to Other, please list:
Please use a comma ( , ) to separate multiple medications.
How many years have you used corrective eyewear?      
 
Contact Lens Wear
1. Do you currently wear contact lenses? Yes No
2. Did you wear contact lenses in the past? Yes No
3. If yes, what type of lenses do/did you wear?
Soft Daily Wear
Soft Disposible
Soft Toric
Sof Extended Wear
Rigid Gas Permeable
Hard
How many years have you used contact lenses?
How many days has it been since you last wore your lenses?
 
Motivation
Please indicate your reason(s) for wanting to improve your vision.
I hereby understand that the information I have provided is accurate to the best of my knowledge and this information will be used as a determinant in basing my candidacy for laser vision correction.
 

 

 

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