Date/Time of Call____________Staff______________________Patient Name________________
Established pt___ New pt____Referred by________________ DOB/Age__________________
Telephone (work)_____________ (home)_____________Which eye? OD______ OS______ OU______
When did the problem begin? ____________________________How did the problem start? ______________________________
Symptoms: ___dry ___pain ___spots ___ red ___blurry ___flashes ___itchy ___discharge ___light sensitive
Has this happened before?_______________________________Any glasses? ______ Any contact lenses?______ Diabetic?_____Any pre-existing eye problems?___________________________
What regular medications are you taking?___________________What eye medications are you taking?______________________Any allergies?_________________________________________
Where can we reach you now? (home/work)_________________How soon can you arrive at the office?________________Health insurance_______________________________________
Appointment made for__________________________________