Appointment Date: Patient's Name (First and Last): * Birth Date: * Gender: * Address: * City: * State: * Zip Code: * Employer: Occupation: Phone Number: * Emergency Contact: Date of Last Eye Exam: Name of Previous Eye Doctor: Name of Your Primary Care Physician: * Are you in good health? * Are you Pregnant and/or Nursing? Personal Medical Information: Do you have any eye disease or systemic disease? * If so, please explain the disease(s):

Please Select Yes or No for the Following Questions:

Do you smoke? Do you drink alcohol? Do you take medications? If yes, please list names & how often: Any allergic reactions to medication or other substances? * If yes, please list the medication(s) and/or substance:

Do you or anyone in your immediate family (that is brothers, sisters, parents, or grandparents) have any of the following? If yes, please check the box that applies and explain in the box below.

Please explain any boxes you have checked:

Do any of the following apply to you? If so, please check each box that applies.

Are you having any eye problems at this time? Are you interested in wearing contact lenses?

Please electronically sign below that you have reviewed all information above and it is correct to the best of your knowledge.

Signature: * Date: *