Eye Care Information

Page 1 of 5
1. First Name(*)
   First Name is Required
2. Last Name(*)
   Last Name is Required
3. Date of Birth(*)
   Day01020304050607080910111213141516171819202122232425262728293031 / Month010203040506070809101112 / Year192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024Date of Birth is Required
4. Address(*)
   Address is Required
5. City(*)
   City is Required
6. Postal Code(*)
   Postal Code is Required
7. Phone Number(*)
   Please enter phone number in format 123-456-7890
8. Work Phone Number
   Please enter phone number in format 1234567890 or 123-456-7890
9. Email(*)
   Email Address is Required
10.  

Page 2 of 5
1. Medical History: Have you ever had any of the following? (Please check if yes)
   Painful Eyes /
   Temporary Loss of Vision /
   Temporary Blurred Vision /
   Headaches /
   Discharge from Eyes /
   Red Eyes /
   Dry Eyes /
   Thyroid Imbalance /
   Cataract /
   Glaucoma /
   Eye Infection /
   Diabetes /
   Heart Problems /
   High Blood Pressure /
   Extreme Sun or Light Sensitivity /
   Double Vision /
   Eye Injury /
   Crossed Eye /
   Eye Medications /
   Lazy Eyes / Invalid Input
2.  

Page 3 of 5
1. Medications (Please List):
2. Medication 1.
   Invalid Input
3. Medication 2.
   Invalid Input
4. Medication 3.
   Invalid Input
5. Allergies (Please List);
6. Allergy 1.
   Invalid Input
7. Allergy 2.
   Invalid Input
8. Allergy 3.
   Invalid Input
9.  

Page 4 of 5
1. Reason for Today's Visit?
2. Do you have trouble seeing any of the following?
   Far Away /
   Close Up /
   Arm's Length /
   At Night / Invalid Input
3. Do you? Or have you ever?
   Worn Glasses /
   Worn Contact Lenses /
   Had an Eye Patch / Invalid Input
4. Have you ever had Surgey? If yes provide reason:
   Invalid Input
5. Have you required Hospitalization within last year?
   Invalid Input
6.  

Page 5 of 5
1. Acknowledgement: By placing my initials and date I hereby give my permission to Sight N' Steps to examine and treat my eyes. I acknowledge that an Optometrist will charge a fees for services that is payable on completion on treatment.
2. Acknowledgement Date(*)
   Invalid Input
3. Acknowledgement Initials(*)
   Invalid Input
4. Do you want to submit additional eye care information forms for family members (common information will be copied)?(*)
   YesNoInvalid Input
5. Please enter the numbers in the image(*)
   
     RefreshInvalid Input