Fair View Eye Care
Patient Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail
example@example.com
Occupation
Employer
Emergency Contact
-
Area Code
Phone Number
Phone #
-
Area Code
Phone Number
Reason for Visit: (Eye Exam, Dry Eye, etc):
Do you currently wear:
Glasses
Contacts
Both
None
Personal / Family History:
Yes
No
Family
Blindness
Cataracts
Glaucoma
High Blood Pressure
High Cholesterol:
Macular Degeneration
Diabetes
(If yes) Last A1C
Date
-
Month
-
Day
Year
Date
Blood Sugar
Date
-
Month
-
Day
Year
Date
Are you experiencing any of the following:
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Itching
Allergies
Dry Eyes
Eye pain or irritation
Flashes or Floaters
Amblyopia / Strabismus
Injuries to Eye even as a child)
(If yes) Age
Current Medication
Medication/Food Allergies:
Tobacco
Yes
No
Packs Per Week/Day
Alcohol
Yes
No
Drinks Per Wk/Day
Narcotics
Yes
No
Height (ft , in)
Weight (lbs)
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: