Patient Information Form | Download PDF | Printable Form | Barrett Vision Center

Name

First Last

Occupation

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Daytime Phone

Evening Phone

Date of Birth

Email

May we contact you by email and text messaging?

Yes
No

FOR CHILDREN UNDER 18 YEARS OF AGE

Mother's Name

Mother's Address

Mother's Daytime Phone

Mother's Evening Phone

Mother's Date of Birth:

Father's Name

Father's Address

Father's Daytime Phone

Father's Evening Phone

Father's Date of Birth

Please answer the questions to the best of your knowledge:

Do you wear glasses?

Yes
No

Going to purchase glasses?

Yes
No

Frequently get headaches?

Yes
No

Have you ever had eye surgery?

Yes
No

Are you Diabetic?

Yes
No

Do you wear contact lenses?

Yes
No

Interested in contact lenses?

Yes
No

Do you ever see double?

Yes
No

Eye Injury?

Yes
No

If female, are you pregnant?

Yes
No

Have you or a blood relative ever had any of the following:

Glaucoma?

Yes
No

Macular Degeneration?

Yes
No

Lazy eye/Amblyopia?

Yes
No

Turned/Crossed eye?

Yes
No

Colorblindness?

Yes
No

Diabetes?

Yes
No

Do you use drops or medications for your eyes?

Yes
No

If yes, please list:

Are you presently taking any medication (any medication at all)?

Yes
No

If yes, please list:

Are you allergic to any medication (any medication at all)?

Yes
No

If yes, please list:

Are you having any problems with your eyes at the current time?

Yes
No

If yes, please state:

Questions or comments:

Patient Information Form for Eyes By Dr. B