Welcome Back 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:
Eye Injury?
Right eye
Left Eye
Both Eyes
None
Eye surgery?
Right eye
Left Eye
Both eyes
None
Cataracts?
Right eye
Left eye
Both eyes
None
Glaucoma?
Right eye
Left eye
Both eyes
None
Macular Degeneration?
Right Eye
Left eye
Both eyes
None
Amblyopia?
Right Eye
Left Eye
Both Eyes
None
Retinal disease?
Right Eye
Left Eye
Both Eyes
None
Any other eye diseases?
Right Eye (please describe below)
Left eye (please describe below)
Both eyes (please describe below)
None
Please list any new or ongoing problems that you are having with your eyes since your last visit:
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 distance vision*
Right
Left
Both
None
Blurred Near Vision*
Right eye
Left eye
Both eyes
None
Blurred intermediate vision*
Right
Left
Both
None
(for example, computer monitors or the dashboard in your car)
Eye Pain or Soreness*
Right
Left
Both
None
Sandy/Gritty sensation*
Right
Left
Both
None
Dry eyes*
Right
Left
Both
None
Poor night vision*
Right
Left
Both
None
Light Sensitivity*
Right
Left
Both
None
Haloes around lights*
Right
Left
Both
None
Watery eyes*
Right
Left
Both
None
Itchy eyes*
Right
Left
Both
None
Tired eyes*
Right
Left
Both
None
Burning eyes*
Right
Left
Both
None
Complete loss of vision*
Right
Left
Both
None
Crossed eyes*
Right
Left
Both
None
Wandering eye*
Right
Left
Both
None
Double vision*
Right
Left
Both
None
Floaters or spots in vision*
Right
Left
Both
None
Flashes of light in vision*
Right
Left
Both
None
Mucus discharge*
Right
Left
Both
None
Eye infection*
Right
Left
Both
None
Eye redness*
Right
Left
Both
None
Eye strain*
Right
Left
Both
None
Droopy eye lid*
Right
Left
Both
None
Migraine headache*
Right
Left
Both
None
Any other headache*
Right
Left
Both
None
Personal Medical History: Have you ever been diagnosed with any of the following? (If no, please check ‘none’)
Cardiovascular*
High blood pressure
Heart disease
High cholesterol
Stroke
Vascular disease
Other (please note below)
None
Constitutional*
Cancer (please list type below)
Developmental disability
Recent weight gain/loss
Loss of appetite
Night sweats
Other (please note below)
None
Neurological*
Multiple Sclerosis
Epilepsy or seizure disorder
Cerebral Palsy
Frequent Headaches
Other (please note below)
None
Hematological*
Anemia
Leukemia
Clotting disorder
Dyscrasia
Other (please note below)
None
Dermatological*
Eczema
Rosacea
Acne
Psoriasis
Atopic dermatitis
Other (please note below)
None
Endocrine*
Diabetes (Insulin dependent)
Diabetes (non-insulin dependent)
Thyroid disorder
Hormonal dysfunction
PCOS
Other (Please note below)
None
Musculoskeletal*
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Gout
Other (please note below)
None
Gastrointestinal*
Acid Reflux
Crohn's disease
Inflammatory Bowel disease/syndrome
Other (please note below)
None
Respiratory*
Asthma
COPD
Emphysema
Bronchitis
Cystic Fibrosis
Sarcoidosis
Other (Please note below)
None
Psychiatric*
Depression
Anxiety disorder
ADHD/ADD
Bipolar disorder
Schizophrenia
Other (please note below)
None
Immunologic*
HIV or AIDS
Rheumatoid Arthritis
Lupus
Allergic disorder
Neurofibromatosis
Scleroderma
Sjogren's syndrome
Other (please note below)
None
Ear/Nose/Throat*
Hearing loss
Upper respiratory infection
Sinus disorder
Tinnitus
Meniere's disease
Other (please note below)
None
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)*
Draw
Type
Upload
Choose your signature image
Date*
/
/
Your form has been saved. You can complete it via this link within 60 days.
Copy
Submit