Form preview
The Ophthalmology Intake Form serves ophthalmologists, optometrists, and vision care clinics. It captures comprehensive eye health information: current vision symptoms, vision correction history (glasses and contact lens prescriptions), previous eye surgeries and procedures, eye disease family history, and occupational vision demands.
The symptom section is tailored for eye care with specific questions about blurred vision, floaters, flashes, double vision, eye pain, dryness, and light sensitivity. These detailed symptom descriptors help the provider focus the examination and anticipate potential diagnoses.
Family eye disease history covers glaucoma, macular degeneration, cataracts, retinal detachment, and other hereditary conditions. The occupational section captures screen time, driving requirements, and specialized vision needs that inform prescription decisions. This template also works well for pre-operative evaluations for LASIK, cataract surgery, and other eye procedures.
What's included
- Vision symptom checklist (floaters, flashes, blur)
- Glasses and contact lens prescription history
- Eye surgery and procedure history
- Family eye disease screening
- Occupational vision demands assessment
- Eye medication documentation
- Medical conditions checklist
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Ophthalmology practices
- Optometry offices and vision clinics
- LASIK and refractive surgery centers
- Retina and glaucoma specialty clinics
All form fields
10 fields across 2 pages. Customize any field after signing up.
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