Spectacle: Eye Exam Intake Form

Hey there! Welcome!

We're so excited you're choosing us for your eye care. To make your visit quick and easy, please take a moment to fill out this short form. The more we know about you and your eyes, the better we can help you see your best.

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Please indicate the location of your eye exam:  *
Full Name
Date of Birth
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Phone Number
Email Address
What is the primary reason for today's visit?
Do you currently wear glasses or contact lenses?
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When was your last eye exam? (or estimated date)
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YYYY
Have you ever had any eye injuries or surgeries?
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If yes, please describe:
Do you have any of the following medical conditions? (Select all that apply)
If 'Other', please specify:
Are you currently taking any medications? (Include over-the-counter medications and supplements)
Do you have any allergies (medications, environmental, etc.)?
How would you rate your current vision?
Poor
Excellent
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On a scale of 1 to 5, how concerned are you about your current eye health?
Not Concerned
Very Concerned
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Please indicate any symptoms you are currently experiencing:
Not at all
Occasionally
Constantly
Blurry Vision
Double Vision
Eye Strain
Dry Eyes
Redness
Itching
Light Sensitivity
Headaches
Floaters
Flashes of Light
Is there anything else you would like us to know about your eye health or medical history?
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