At City Eyes Optometry Center, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

  • You will need AdobeReader® to download and complete the forms. Click here to download.

  • Download the required form(s). Print out the form(s) and complete the required information.

  • Fax your printed and completed form(s) to our office or bring them with you to your appointment.

New Patient Health History Form – Required


Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

Online Patient History Form

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PATIENT HISTORY QUESTIONAIRE
Full Name
Address / City / State / Zip Code
Telephone Number:
Social Security Number:
Date of Birth:
Employer:
Occupation:
Emergency Contact Name/Number:
Date of Last Eye Exam:
Reason For Today's Visit:
Email
MEDICAL HISTORY
How is your General Health?
Do you have any problems with any of these systems?
Ears / Nose / Throat
Genitourinary
Endocrine
Cardiovascular
Eye
Gastrointestinal
Nervous
Mental
Musculoskeletal
Blood / Lymph
Respiratory
Integumentary (skin)
Allergic / Immunologic
Please Explain:
Please answer all that apply:
Diabetes
Type:
Date of diagnosis:
Allergies
Allergic to:
What happens:
Medication Allergy
What happens:
Headaches
Other health problems:
Current medication (s):
Have you had any operations?
What kind?
When:
Do you use cigarettes / tobacco?
Alcohol?
Other substances:
Name of family doctor:
Date of last visit:
FAMILY HISTORY
High blood pressure
Relation
Mascular degeneration
Relation
Diabetes
Relation
Retinal Detachment
Relation
Glaucoma
Relation
Cataracts
Relation
Other eye condition (s)
What kind?
PERSONAL EYE INFORMATION
Have you had any eye operations?
Type:
Date
Have you had any eye injury?
Kind:
Date
Do you have glaucoma?
Cataracts?
Dry Eyes?
Blurred Vision?
Other eye problems?
What kind?
Do you wear glasses?
Contact lenses?
If so, what type?
Are you interested in wearing contact lenses?
Additional Information
Are you interested in Lasik refractive eye surgery?
What hoobies or sports do you participate in?
Whom may we thank for referring you to us?
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