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Welcome to Eye Rx

To help make your first visit as smooth and efficient as possible, we ask new patients to complete the form below before arriving at your appointment. This information allows your doctor to review your medical and vision history in advance and tailor your exam to your specific needs.

If you have any questions while completing the form, our team is always available to help.

Thanks for contacting us! We will get in touch with you shortly.

Please complete this new patient paperwork form.

Name *
Today's Date *
Date of Birth *
Sex *
*
Address *
*
*
routine, new glasses, contact lens evaluation, red/painful eye, diabetic exam, medical visit etc.

Medical History

Do you currently have any problems in the following areas? If YES, please provide additional information.

EYES (glaucoma, cataracts, retinal conditions, macular degeneration, corneal conditions etc.) *
ENDOCRINE (diabetes, thyroid etc.) *
EARS, NOSE, THROAT (deafness, stuffy nose, earache, cough, dry mouth etc.) *
GENERAL/CONSTITUTIONAL (fever, heat stroke, weight loss/gain etc.) *
CARDIOVASCULAR (hypertension, cholesterol, stroke, heart attack etc.) *
RESPIRATORY (asthma, wheezing, short of breath etc.) *
GASTROINTESTINAL (IBS, diarrhea, constipation, hernia, ulcers etc.) *
GENITAL, KIDNEY, BLADDER (painful/frequent urination, jaundice, etc.) *
FEMALES - Are you pregnant? Nursing? *
MUSCLES, BONES, JOINTS (joint pain, stiffness, cramps, arthritis, etc.) *
SKIN (eczema, growths, rash, warts etc.) *
NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) *
PSYCHIATRIC (anxiety, depression, insomnia) *
BLOOD/LYMPH (anemia, leukemia etc.) *
ALLERGIC/IMMUNOLOGIC (seasonal, lupus etc.) *

Family History

(mother, father, grandparent, sibling)

Has any member of your family had these diseases? *
Blindness, Cataract, Glaucoma, Retinal/Corneal diseases, Diabetes, Hypertension, Heart Disease, Stroke, Cancer, Thyroid Disease, Arthritis, Other heritable disease
Do you have allergies to any medications? *
*
Date *
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Questions Before or After Submitting Your Form? »

If you have questions about your appointment, need help with the form, or prefer to complete paperwork in the office, our team is here to assist you. Contact your Eye Rx location at any time, and we will be happy to guide you through the next steps and help you prepare for your visit.

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