EyeWorks, Vision Center

1800.443.7803

EyeWorks Patient Information
Last Name:
First Name:
Gender:		Male Female
Date of Birth:
Street Address:
City:
State:
Zip:
Phone:
Work Phone:
Employer:
Referred by:
Appointment already scheduled? If so, when?
If not, when would you like an appointment?
To stay up to date with current eye health issues and to confirm appointments online please provide your email address:
Questionnaire
Please check everything that applies to you:		Computer use averages more than 1 hour daily Pregnant or Nursing Drink less than 3 glasses of water daily Use bedroom ceiling fan Drink 3 or more caffeinated beverages daily Contacts lens wearer Consume 3 or more servings of fish per week Read 1 or more hours daily Travel by plane more than twice a month Consumer of tobacco products Sleep 7 hours or less per night Take more than 3 medications
Do you currently take any of the following medications? (Please check all that apply)		Birth control (orally) Blood Pressure Medications Active bladder therapy Anti-depressants Antihistamines Diuretics (LASIX) Hormone therapy Accutane (past or present)
Do you use any of the following eye drops? (Please check all that apply)		Glaucoma drops Allergy drops Other:
Over the past year, which of the following symptoms have you experienced?		Stinging Dry mouth Crusty lids or lashes Aching Tearing Light sensitivity Decreased contact lens wear Dryness Itching Blurred vision Fluctuating vision (i.e. clarity) Glare Grittiness Redness/Swelling Difficulty with night driving Burning
Have you ever had eye surgery (LASIK, PRK, Cataract Surgery, Other)?		Yes (please specify:) No
Have you been diagnosed with any of the following conditions?
		Thyroid Disease Arthritis Sarcoidosis Shingles Diabetes Rosacea Sleep disorders Multiple Sclerosis
Do you use artificial tears or "re-wetting" drops?		Yes (please specify brand:) No
How long does relief last after using artificial tears?
How many artificial tear drops do you use daily?
Do you get headaches?		Yes No How often?