Welcome to Clarity Eye Care!
Please complete the following information to help us understand you and your eyes.
Date*
-
-
Date of Exam
First name*
Legal first name
Middle initial
Middle initial
Last name*
Last name
Preferred name/Nickname
What should we call you?
Pronouns
She/her, He/they, etc.
Date of Birth*
Age*
Marital Status*
Choose One
Single
Married
Divorced
Widowed
Other
Gender*
Choose One
Male
Female
Non-Binary
Other
Prefer not to answer
Last 4 of Social security number*
Street Address*
City*
State*
Zip code*
Primary phone number*
Primary phone type*
Home
Work
Cell
Alternate phone number
Alternate phone type
Home
Work
Cell
Email address*
Preferred Language*
Race*
American Indian/Alaskan Native
Black/African American
Native Hawaiian/Pacific Islander
Asian
Hispanic
White
select all that apply
Ethnicity*
Hispanic/Latinx
Non-Hispanic/Latinx
Hawaiian/Pacific Islander
select all that apply
How may we contact you?*
Phone
Text
E-mail
Mail
(choose all that apply)
Current employer or Current school*
Current Occupation or Current School grade*
Parent/Legal guardian name*
Parent/Legal guardian phone number*
Emergency Contact*
Relation to patient*
Emergency contact phone number*
Who may we thank for referring you?
Do you wear glasses at all?*
Yes
No
Used to, but not anymore/recently
When do/did you wear your glasses?*
All the time
Sometimes
Work/computer only
Reading only
Driving only
How long ago did you get your current glasses?*
Do you wear contact lenses at all?*
Yes
No
Used to, but not anymore/not recently
I Would like to try contact lenses
When do you/did you usually wear contact lenses?*
Every day
Most days
Special occasions
Overnight
What is your contact lens replacement schedule?*
Daily
2 weeks
Monthly
Yearly
What brand are your contact lenses? (if known)
Which contact lens solution do you use?
Choose One
Opti-Free PureMoist
Opti-Free Replenish
Clear Care Plus
BioTrue
PeroxiClear
Acuvue Revitalens
Unique PH
Boston Simplus
Boston Complete (2-step)
ReNu
Store brand
Unknown/Other
None
Do you wear sunglasses?*
Choose One
Yes
No
Occasionally
How many hours per day do you use a screen (computer/tablet/phone)?*
Choose One
0-2 hours
2-4 hours
4-8 hours
8-12 hours
12-16 hours
16+ hours
What is the approximate date of your last MEDICAL exam?*
(approximate date is OK)
Primary Care Doctor name*
Medical clinic name/Location*
Date of last EYE exam*
(approximate is ok)
Eye Doctor name*
Office name/Location of last eye exam*
Have YOU ever had or been diagnosed with:
An Eye injury?*
Yes
No
Which eye(s) had an injury?*
Right eye
Left Eye
Both Eyes
Eye Surgery?*
Yes
No
Which eye(s) had surgery?*
Right eye
Left Eye
Both eyes
Cataracts?*
Yes
No
Which eye(s) had Cataracts?*
Right eye
Left eye
Both eyes
Glaucoma?*
Yes
No
Which eye(s) have Glaucoma?*
Right eye
Left eye
Both eyes
Macular Degeneration?*
Yes
No
Which eye(s) have Macular Degeneration?*
Right Eye
Left eye
Both eyes
Amblyopia?*
Yes
No
Which eye(s) have Amblyopia?*
Right Eye
Left Eye
Both Eyes
Retinal disease?*
Yes
No
Which eye(s) have Retinal disease?*
Right Eye
Left Eye
Both Eyes
Any other eye diseases?*
No
Right Eye (please describe below)
Left eye (please describe below)
Both eyes (please describe below)
Please list any details on the above eye conditions if applicable:
Are you currently pregnant?*
Yes
No
N/A
Are you currently breastfeeding?*
Yes
No
N/A
Are you CURRENTLY or RECENTLY experiencing any of the following with your eyes?
Blurred Vision?*
Yes
No
At what distances does your vision feel blurry?*
Far away
Close up
Intermediate (computer, car dashboard)
Which eye(s) feel blurry far away?*
Right eye
Left eye
Both eyes
Which eye(s) feel blurry up close?*
Right eye
Left eye
Both eyes
Which eye(s) feel blurry at intermediate distances?*
Right Eye
Left Eye
Both Eyes
(For example, computer monitors or dashboard in car)
Irritated or uncomfortable feeling?*
Yes
No
(Dry, watery, itchy, tired, burning, sore, strained, or painful)
What do your eyes feel like when they are uncomfortable?*
Painful or Sore
Sandy/Gritty
Dry
Itchy
Burning
Watery
Tired
Strained
Which eye(s) feel painful or sore?*
Right
Left
Both
Which eye(s) feel sandy or gritty?*
Right
Left
Both
Which eye(s) feel dry?*
Right
Left
Both
Which eye(s) feel itchy?*
Right
Left
Both
Which eye(s) feel like they burn?*
Right
Left
Both
Which eye(s) feel tired?*
Right
Left
Both
Which eye(s) feel strained?*
Right
Left
Both
Which eye(s) feel watery?*
Right
Left
Both
Poor night vision?*
Yes
No
Which eye(s) are experiencing poor night vision?*
Right
Left
Both
Light sensitivity?*
Yes
No
Which eye(s) experience Light Sensitivity?*
Right
Left
Both
Glare or haloes around lights?*
Yes
No
Which eye(s) see Haloes around lights?*
Right
Left
Both
Complete loss of vision?*
Yes
No
Which eye(s) have experienced a Complete loss of vision?*
Right
Left
Both
Crossed or wandering eyes?*
Yes- crossed
Yes- wandering
No
Which eye is crossed?*
Right
Left
Both
Which eye is wandering?*
Right
Left
Both
Double vision?*
Yes
No
Which eye(s) is experiencing double vision?*
Right
Left
Both
Flashes or floaters in vision?*
Yes
No
Which eye(s) is experiencing Floaters or spots in vision?*
Right
Left
Both
Neither
Which eye(s) is experiencing Flashes of light in vision?*
Right
Left
Both
Neither
Mucus Discharge?*
Yes
No
Which eye(s) have Mucus discharge?*
Right
Left
Both
Eye infection?*
Yes
No
Which eye(s) have had an infection?*
Right
Left
Both
Eye redness?*
Yes
No
Which eye(s) seem red?*
Right
Left
Both
Drooping eye lid(s)?*
Yes
No
Which eye lid feels droopy?*
Right
Left
Both
Migraine headaches?*
Yes
No
Any other headaches?*
Yes
No
Personal Medical History: Have you ever been diagnosed with any of the following?
Cardiovascular disorder?*
Yes
No
(For example: High Blood pressure, Heart disease, High Cholesterol, Stroke, or Vascular disease)
Which Cardiovascular condition(s) do you have?*
High blood pressure
Heart disease
High cholesterol
Stroke
Vascular disease
Other (please note below)
Constitutional disorder?*
Yes
No
(For example: Cancer, Developmental Disability, Weight gain/loss, Loss of appetite, or Night sweats)
Which Constitutional disorder(s) do you have?*
Cancer (please list type below)
Developmental disability
Recent weight gain/loss
Loss of appetite
Night sweats
Other (please note below)
Neurological disorder?*
Yes
No
(For example: Multiple Sclerosis, Epilepsy, Seizures, Cerebral Palsy, or Frequent headaches)
Which Neurological disorder(s) do you have?*
Multiple Sclerosis
Epilepsy or seizure disorder
Cerebral Palsy
Frequent Headaches
Other (please note below)
Hematological disorder?*
Yes
No
(For example: Anemia, Leukemia, Clotting disorders, Dyscrasia)
Which Hematological disorder(s) do you have?*
Anemia
Leukemia
Clotting disorder
Dyscrasia
Other (please note below)
Dermatological disorder?*
Yes
No
(For example: Eczema, Rosacea, Acne, Psoriasis, or Atopic Dermatitis)
Which Dermatological disorder(s) do you have?*
Eczema
Rosacea
Acne
Psoriasis
Atopic dermatitis
Other (please note below)
Endocrine disorder?*
Yes
No
(For example: Diabetes, Thyroid disorder, Hormonal Dysfunction, or PCOS)
Which Endocrine disorder(s) do you have?*
Diabetes (Insulin dependent)
Diabetes (non-insulin dependent)
Thyroid disorder
Hormonal dysfunction
PCOS
Other (Please note below)
Musculoskeletal disorder?*
Yes
No
(For example: Osteoarthritis, Fibromyalgia, Muscular dystrophy, Ankylosing Spondylitis, or Gout)
Which Musculoskeletal disorder(s) do you have?*
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Gout
Other (please note below)
Gastrointestinal disorder?*
Yes
No
(For example: Acid reflux, Crohn's disease, Inflammatory Bowel disease/syndrome)
Which Gastrointestinal disorder(s) do you have?*
Acid Reflux
Crohn's disease
Inflammatory Bowel disease/syndrome
Other (please note below)
Respiratory disorder?*
Yes
No
(For example: Asthma, COPD, Emphysema, Bronchitis, Cystic Fibrosis, or Sarcoidosis)
Which Respiratory disorder(s) do you have?*
Asthma
COPD
Emphysema
Bronchitis
Cystic Fibrosis
Sarcoidosis
Other (Please note below)
Psychiatric disorder?*
Yes
No
(For example: Depression, Anxiety, ADHD/ADD, Bipolar, or Schizophrenia)
Which Psychiatric disorder(s) do you have?*
Depression
Anxiety disorder
ADHD/ADD
Bipolar disorder
Schizophrenia
Other (please note below)
Immunologic disorder?*
Yes
No
(For example: HIV/AIDS, Rheumatoid Arthritis, Lupus, Allergic disorders, Neurofibromatosis, Scleroderma, or Sjogren's syndrome)
Which Immunologic disorder(s) do you have?*
HIV or AIDS
Rheumatoid Arthritis
Lupus
Allergic disorder
Neurofibromatosis
Scleroderma
Sjogren's syndrome
Other (please note below)
Ear/Nose/Throat disorder?*
Yes
No
(For example: Hearing loss, Upper respiratory infection, Sinus disorders, Tinnitus, or Meniere's disease)
Which Ear/Nose/Throat disorder(s) do you have?*
Hearing loss
Upper respiratory infection
Sinus disorder
Tinnitus
Meniere's disease
Other (please note below)
Other conditions not listed above or notes on above conditions:
Do you use alcohol?*
Yes
No
How often do you drink alcohol?*
Social, 1-2 drinks per week
1-2 drinks per day
>2 drinks daily
Do you smoke or vape?*
Yes
No
Formerly smoked/vaped
How much do you smoke or vape?*
Occasionally
Less than 1 pack or cartridge per day
1 or more packs or cartridges per day
Are you allergic to any MEDICATIONS?*
Yes (please list below)
No
Are you allergic to any foods, pollens, dust, or anything else?*
Yes (please list below)
No
Please list ALL known allergens (including medications, animals, foods, and pollens)*
Please list any and all medications that you are currently taking, INCLUDING prescription and non-prescription medications, creams, and eye drops, vitamins, and supplements, along with what you are taking them for. If you are not taking any medications, please list 'none'
If you would prefer to bring a medication list with you rather than listing them here, please check this box.
Medication #1*
if you are not using any medications or supplements, please type 'none'
What do you take it for?*
Medication #2
What do you take it for?
Medication #3
What do you take it for?
Medication #4
What do you take it for?
Medication #5
What do you take it for?
Medication #6
What do you take it for?
Medication #7
What do you take it for?
Medication #8
What do you take it for?
Medication #9
What do you take it for?
Medication #10
What do you take it for?
Medication #11
What do you take it for?
Medication #12
What do you take it for?
Medication #13
What do you take it for?
Medication #14
What do you take it for?
Family history: Have any of your blood relatives (parents, grandparents, children, living or deceased) been diagnosed with any of the following:
High blood pressure?*
Yes
No
Unknown
Who in your family has/had high blood pressure?*
Diabetes?*
Yes
No
Unknown
Who in your family has had diabetes?*
Cancer?*
Yes
No
Unknown
Who in your family has had cancer, and what type(s)?*
Heart disease?*
Yes
No
Unknown
Who in your familiy has had heart disease?*
Thyroid disease?*
Yes
No
Unknown
Who in your family has had thyroid disease?*
Retinal detachment?*
Yes
No
Unknown
Who in your family has had a Retinal Detachment?*
Blindness?*
Yes
No
Unknown
Who in your family has a history of blindness?*
Cataracts?*
Yes
No
Unknown
Who in your family has had cataracts?*
Glaucoma?*
Yes
No
Unknown
Who in your family has had glaucoma?*
Crossed or Lazy eyes?*
Yes
No
Unknown
Who in your family has had crossed or lazy eyes?*
Macular Degeneration?*
Yes
No
Unknown
Who in your family has had Macular Degeneration?*
Any other eye diseases or conditions?*
Yes
No
Unknown
Please list any other known eye diseases in your family history:*
HIPAA Authorization and release: I authorize the release of any information including the diagnosis and records of any treatment or examinations rendered to me or my dependent to:*
Please list the name(s) of any other adult(s) you would like to have access to this patient's medical information for any reason
HIPAA PRIVACY PRACTICE ACKNOWLEDGEMENT I am aware of Clarity Eye Care’s Notice of Privacy Practices. Would you like a copy of our HIPAA policy?*
Yes
No
Patient Signature (or legal guardian if patient is a minor)*
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