INTAKE FORM Please complete this form with as much detail as you can. PrefixMr.Ms.Mrs.Other Address Medical History This information is kept strictly confidential, however you may discuss this directly with the doctor if you prefer. Do you drive? YesNo Do you use tobacco products? YesNo Do you drink alcohol? YesNo Do you use illegal drugs? YesNo Review of Systems Ears, nose, mouth, throat YesNo Cardiovascular, (heart,blood vessels) YesNo Respiratory (lungs/breathing) YesNo Gastrointestinal (stomach/intestines) YesNo Genitourinary (genitals/kidney/bladder) YesNo Musculoskeletal (muscles/joints) YesNo Integument (skin/breast) YesNo Neurological YesNo Psychiatric YesNo Endocrine (hormones, glands) YesNo Hematologic/Immunologic (blood) YesNo Seasonal allergies (hay fever, etc.) YesNo Vision History Past Eye Injury YesNoUnknown Loss of Vision YesNoUnknown Blurred / Distorted Vision YesNoUnknown Redness YesNoUnknown Itching YesNoUnknown Burning YesNoUnknown Excess Tearing / Watering YesNoUnknown Halos / Glare YesNoUnknown Eye Pain or Soreness YesNoUnknown Sandy or Gritty Feeling YesNoUnknown Dizziness YesNoUnknown Flashes / Floaters YesNoUnknown Double Vision YesNoUnknown Tired Eyes YesNoUnknown Prone to Motion Sickness YesNoUnknown Feeling overwhelmed in Busy Environments YesNoUnknown Strabismus (crossed / lazy eye) YesNoUnknown Loses place when reading YesNoUnknown Headaches YesNoUnknown Light sensitivity YesNoUnknown Poor comprehension YesNoUnknown Struggle with keeping up in school YesNoUnknown Reason For Visit Other Therapies/Treatments Medications No Medications Drug Allergies No Drug Allergies Medical History No Medical History Family History No Family History
