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Patient History Form
Personal and Social History
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* Indicates required question
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Occupation
*
Your answer
Employer
*
Your answer
E-Mail Address
*
Your answer
Preferred Phone Number
*
Home
Cell
Telephone Number
*
Your answer
Current Home Address (street, town, state, zip code)
*
Your answer
Do you wear contacts
*
Yes
No
Do you have an interest in wearing contacts?
*
Yes
No
Primary Care Doctor (name, town and phone number)
*
Your answer
Pharmacy (name and town)
*
Your answer
Medications
*
Your answer
Drug, Food or Seasonal Allergies
*
Your answer
Past Diagnosed Eye Conditions
Your answer
Alcohol Consumption
Yes
No
Clear selection
If yes, how much alcohol (on average) do you consume per day?
Your answer
Current Smoker
Yes
No
Quit
Clear selection
If yes, how much (on average) do you smoke per day?
Your answer
Do you wear (or have you ever worn) glasses?
*
Yes
No
If yes, how old is current pair of glasses?
Your answer
Do you wear sunglasses?
Yes
No
Clear selection
How many hours per day do you spend on a computer or smartphone?
Your answer
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