Name*

First Last

Date of Birth*

Address*

Street Address City State ZIP Code

How did you hear about us?

Who referred you? We would like to send them a Thank You.

Briefly describe any problems your experiencing with your eyes or vision.

Current Eye Problems

None
Itchy / allergy eyes
Dry eyes
Glaucoma
Strabismus (lazy eye)
Cataracts
Macular degeneration

Past Eye Problems

None
Conjunctivitis (pink eye)
Eye allergies
Corneal abrasion
Eye surgery
Eye injuries
Corneal ulcer
Styes / eyelid infections

Do any FAMILY MEMBERS have any eye problems?

None
Cataracts
Glaucoma
Macular degeneration
Retinal detachment
Lazy eye / amblyopia
Blindness

Do you wear glasses?

Do you wear sunglasses when outdoors?

Do you wear contact lenses?

What BRAND of contacts do you wear?

Contact Lens Power LEFT EYE

Contact Lens Power RIGHT EYE

Do you have any medical conditions?*

Yes (select conditions below)
None

Please select any conditions you have.

List any medications you currently take

List any medications you are ALLERGIC to

Primary care physician name

What is your occupation?

Please list any hobbies or sports you participate in.

Have you ever smoked?

Notice of Privacy Practices

Our Notice of Privacy Practices is a complete description of how O’Fallon Family Eyecare uses and protects your medical information and personal data. If you have not already received a copy of our Privacy Practices, please ask one of our staff members for a printed copy or we can e-mail it to you in PDF format. By checking this box, you are only acknowledging that you have received a copy of our Notice of Privacy Practices or had the opportunity to review the notice. You can also ask for a copy when you arrive for your appointment.

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