Forsight Vision Care

General Information

Name (required, at least 2 characters)

Phone Number (required)

City (required)

State (required)

Zip Code (required)

E-Mail (required)

Are you presently taking any medications?

Y/N, If yes, please list (required)

Do you have any allergies

Y/N, If yes, please list (required)

Have you ever had eye surgery?

Type, which eye and approximate dates (required)

Do you have or have you ever worn eyeglasses?

Y/N If yes, how old is prescription (required)

Do you wear or have you ever worn contact lenses?

Y/N If no, are you interested (required)

If yes, how old is your prescription

Are they comfortable

Type of contact lenses

Do you work on a computer?

Y/N If yes, how many hours per day? (required)

FAMILY HISTORY | Does anyone in your family have or been treated for:

Y/N Glaucoma

Y/N Retinal Problems

Y/N High blood pressure

Y/N Diabetes

Y/N Cataract

Y/N Thyroid Problems

Y/N Macular Degeneration

Y/N Diabetes

SOCIAL HISTORY | This information is kept strictly confidential Do you use tobacco products?

Y/N, If yes, how long (required)

Do you drink alcohol?

Y/N, If yes, how long (required)

Do you use illegal drugs?

Y/N, If yes, how long (required)

Have you ever been exposed to or infected with:

Gonorrhea, Hepatitis, HIV, Syphilis (required)

Do you currently have or have you had any problem in the following areas? Constitutional - Fever, weight loss/gain

Y/N (required)

Integumentary - Skin condition

Y/N (required)

Neurological - Headaches/Migraines

Y/N (required)

Neurological - Seizures

Y/N (required)

Eyes - Loss of vision

Y/N (required)

Eyes - Blurred Vision

Y/N (required)

Eyes - Distorted Vision/Halos

Y/N (required)

Eyes - Double Vision

Y/N (required)

Eyes - Dryness

Y/N (required)

Eyes - Mucous Discharge

Y/N (required)

Eyes - Redness

Y/N (required)

Eyes - Itching

Y/N (required)

Eyes - Burning

Y/N (required)

Eyes - Foreign Body Sensation

Y/N (required)

Eyes - Tearing/Watering

Y/N (required)

Eyes - Glare or Light Sensitivity

Y/N (required)

Eyes - Flashes/Floaters

Y/N (required)

Endocrine - Thyroid/ Other Glands

Y/N (required)

Ears, Nose, Mouth, Throat - Allergies/Hay Fever

Y/N (required)

Ears, Nose, Mouth, Throat - Sinus congestion

Y/N (required)

Ears, Nose, Mouth, Throat - Chronic Cough

Y/N (required)

Respiratory - Asthma

Y/N (required)

Respiratory - Chronic Bronchitis

Y/N (required)

Respiratory - Emphysema

Y/N (required)

Vascular/Cardiovascular - Diabetes

Y/N (required)

Vascular/Cardiovascular - High Blood Pressure

Y/N (required)

Gastrointestinal - Diarrhea/Constipation

Y/N (required)

Genitourinary - Genitals/Kidney/Bladder

Y/N (required)

Bones/Joint/Muscles - Rheumatoid Arthritis

Y/N (required)

Bones/Joint/Muscles - Muscle/Joint Pain

Y/N (required)

Lymphatic/Hematologic - Anemia

Y/N (required)

Lymphatic/Hematologic - Bleeding Problems

Y/N (required)

Allergic/Immunilogic

Y/N (required)

Psychiatric

Y/N (required)