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    Patient Information

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    Personal Information


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    Please let us know how you were referred to our office.

    Eye History

    I stopped wearing glassesI stopped wearing contact lensesHeadachesGlare/Light SensitivityTired EyesAmblyopia (lazy eye)BurningDrynessWatery EyesEye Pain and/or SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping eyelid(s)RednessSandy or Gritty FeelingStrabismus (crossed eye)Blurred Vision at DistanceBlurred Vision at NearHaloesDouble VisionFloaters or SpotsFluctuating VisionLoss of VisionLoss of Side Vision

    Glasses History


    Contact Lens History


    Medical History

    Chronic fever, unexpected weight loss/gain, fatigueEar/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)Respiratory problems (eg. Shortness of breath, wheezing, coughing)Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)Skin problems (eg. Rashes, excessive dryness, growths or lumps)Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)Psychiatric problems (eg. Depression, anxiety)Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

    Primary Insurance

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    Secondary Insurance



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