Name: ___________________________________________
Address: _________________________________________
City, State, Zip: ___________________________________
Email Address: ___________________________________
Primary Phone: ____________________________________
Date: ______________________________
Birth Date: _________________________
Occupation: _________________________
Gender: M ______ F _______
Secondary Phone: ____________________
Please briefly describe your reason for visit including any symptoms you are experiencing.
History of Present Illness:
Which eye has the problem?
How long ago did the problem start?
Is the condition
_____________________________________
Current Medications, Eye Drops and/or over-the-counter Supplements. Please list:
Allergies: (please list) _______________________________________________________________________
_________________________________________________________________________________________
Please list anything in your past history, family history or social history which would help us care for you:
Do you currently have any of these symptoms?
Flashes/Floaters
Mucous/Discharge
ed Eyes
Do you have a history of the following eye conditions?
Eye Surgery
Vision Therapy/Patching
Other ___________________
Has anyone in your family had any of the above conditions? (please list)
________________________________________________________________________________________
________________________________________________________________________________________
Do you have a history of any of the following conditions?
Vascular Disease
____________________
Anxiety Disorder
______________________
Hypertension
Cancer (specify) _______________________________________
___________________
______________________________
___________________
Has anyone in your family had any of the above conditions? (please list)
________________________________________________________________________________________
________________________________________________________________________________________
Are you a current smoker?
Are you pregnant or nursing?
When was your last eye exam? ______________
Are you a former smoker?
Do you wear sunglasses?
Are you a previous patient of ours?
Are you interested in contact lenses?
Please read and initial each of the following:
________ Our intermediate/glasses examination is $69. Intermediate examination is a prerequisite required in
order to be evaluated for any other reason or to receive any other service.
________ We recommend that your eyes are dilated for a thorough eye health assessment. The drops that we
use, do not usually cause difficulty with driving vision. The fee is $30.
________ Fees for additional examination, treatment, or services will be charged in cases including, but not
limited to, emergencies, eye infections, foreign body removal, dry eye treatment, referral to specialist,
form completion, retinal photography, contact lens fitting etc.
________ Contact lens packages which include contact lens fitting and contact lens materials start at $204 and
may be higher depending the complexity and type of fitting required, as determined by the Dr.
________ Cell phones must be turned off (power off) so that our patients, staff and equipment are not disturbed.
Please let our receptionist know if you must step out of our office to use your phone.
________ Our staff and Doctors care about your experience at our office. We want to give you the best and
most comprehensive examination and care that is possible or available. If at any time we do not
meet your expectations, please bring it to our attention during your visit.
Please answer all of the following:
How did you hear about our office?________________________________________________________________
Year of last medical exam to check cholesterol and diabetes?_______ Doctor?__________________
Blood Relative with Glaucoma? Yes / No Who?________________________
How will you make full payment for today’s fees?_________________
To use an accepted insurance, you must give us your valid insurance card and a picture I.D. prior to examination
Please sign that you have read and understand all of the above .__________________________Date:___/___/____
Intake form WordperfectDDIDD
THANK YOU for trusting us with your Vision and Eye Care
Drs. Vaxmonsky & Baloga Family Eye Care Center