PATIENT QUESTIONAIRRE
*Indicates a
required
field.
Name*
Address*
City*
State*
Zip*
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, 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.