Patient History Form
Personal and Social History
First and Last Name *
Date of Birth *
Occupation *
Employer *
E-Mail Address *
Preferred Phone Number *
Telephone Number *
Current Home Address (street, town, state, zip code) *
Do you wear contacts *
Do you have an interest in wearing contacts? *
Primary Care Doctor (name, town and phone number) *
Pharmacy (name and town) *
Medications *
Drug, Food or Seasonal Allergies *
Past Diagnosed Eye Conditions
Alcohol Consumption
Clear selection
If yes, how much alcohol (on average) do you consume per day?
Current Smoker
Clear selection
If yes, how much (on average) do you smoke per day?
Do you wear (or have you ever worn) glasses? *
If yes, how old is current pair of glasses?
Do you wear sunglasses?
Clear selection
How many hours per day do you spend on a computer or smartphone?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy