[Practice name]
Optometry Intake Form
Appointment date
Doctor
Urgent concerns: If you have sudden vision loss, significant eye trauma, chemical exposure, or severe eye pain, do not wait for this form to be reviewed. Call the practice or seek urgent or emergency care as appropriate.
1. Patient and contact information
Legal name
Name used
Date of birth
Sex for clinical care, if used
Mobile phone
Email
Address, city, state, ZIP
Preferred language
Accessibility or communication needs
Emergency contact, relationship, and phone
Parent, guardian, or responsible party, if applicable
Primary care doctor and location
Preferred pharmacy and location
Preferred contact
CallTextEmail
2. Today's visit and visual needs
Main reason for visit
When did it begin?
Other eye or vision concerns
Last eye exam, approximate date and doctor
Visually difficult work, school, hobbies, or tasks
Which eye?
RightLeftBothNot sure
Current correction
NoneGlassesContactsBoth
Visual needs
DistanceReadingComputerDrivingNight drivingSchoolSportsSafety eyewear
New or sudden symptoms
NoneVision lossFlashesNew floatersCurtain or veilDouble visionEye painRedness or dischargeInjuryChemical exposure
3. Eye health history
No known eye conditionsHistory unknownGlaucoma or suspectCataractMacular degenerationDiabetic retinopathyRetinal tear or detachmentDry eyeKeratoconus or corneal diseaseUveitis or iritisAmblyopia or lazy eyeStrabismus or eye turnHigh myopiaEye injuryOther
Condition, eye, year, and treating doctor
Eye surgeries or procedures, eye, and approximate date
Current eye drops, dose or frequency, and eye
4. Glasses and contact lenses
Glasses
Do not wearFull timePart timeReading onlyWorking wellNot working well
Contact lens status
Do not wearCurrent wearerInterested in contacts
Lens type
SoftRGPScleralOrtho-kOther
Brand and parameters, if known
Replacement schedule
Hours per day and days per week
Comfort and vision
Last date lenses were worn
Care solution or routine
Overnight wear
NoYes
Current problems or goals
5. Medical history
No known conditionsHistory unknownDiabetesHigh blood pressureHigh cholesterolHeart diseaseStrokeThyroid diseaseMigraineAutoimmune diseaseArthritisAsthma or COPDSleep apneaKidney diseaseLiver diseaseCancerNeurologic conditionOther
Details, dates, or treating doctor
Prior surgeries or hospitalizations
Tobacco use
Alcohol or other substance use
Current symptoms by system
NoneGeneralENTHeart or vascularRespiratoryGIGUMusculoskeletalSkinNeurologicPsychiatricEndocrineBlood or lymphAllergy or immune
Positive symptoms or details
Currently pregnant or nursing, if relevant to care
NoYesNot applicablePrefer to discuss with the doctor
6. Medications and allergies
No current medications, vitamins, or supplements
Name
Dose
Frequency
Reason
No known allergiesMedicationLatexOther
Allergen and reaction
7. Family history
None knownHistory unknownGlaucomaMacular degenerationRetinal disease or detachmentBlindnessKeratoconusAmblyopia or strabismusHigh myopiaDiabetesHigh blood pressureStrokeHeart diseaseOther
Condition and affected relative
8. Coverage
Medical insurance
Payer
Member ID and group
Subscriber name and date of birth
Relationship to patient
Card front receivedCard back receivedSecondary coverage
Vision plan
Payer
Member ID and group
Subscriber name and date of birth
Relationship to patient
Card front receivedCard back receivedSecondary coverage
Referral or authorization details, if applicable
9. Patient attestation
I confirm that the information I provided is complete and accurate to the best of my knowledge. I understand that I should tell the practice if this information changes.
Patient or guardian signature
Date
Printed name
Relationship, if guardian
Practice-specific documents to add separately
Notice of Privacy Practices acknowledgmentFinancial policy and assignment of benefitsConsent to treatmentEmail, text, or voicemail communications consentRecords release when requestedContact lens, dilation, imaging, procedure, or specialty consent when applicable
This template is an educational starting point, not legal advice or a substitute for clinical review. Customize it for your state, payers, patient population, EHR, and practice policies.