Gateway Eye Associates
See your best! Look your best! Feel your best!
To save you time on the day of your appointment, please fill out all information below and email it back to us
prior to your appointment. You can also print the filled in form and bring it with you to your appointment. This
will allow us to update any new or changes information about you.
REMINDER: Please bring with you the following items.
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All your eyeglasses.
All your sunglasses, prescription as well as non-prescription.
If you wear contact lenses, the contact lens package.
Your insurance cards.
Health savings card or care credit card.
Form of payment for any copays.
Please contact us if you have any questions. We look forward to seeing you soon!
Date Form Completed:
First name:
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Middle Initial:
Last Name:
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Date of Birth: Click here to enter a date.
Address:
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Home #:
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Work #:
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Cell #:
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Email:
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State:
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Zip: Click here to enter text.
What concerns would you like addressed at your visit? Click here to enter text.
☐ NONE
Or select all that apply:
☐ Blurry vision
☐ Tired eyes
☐ Eye Pain
☐ Light Sensitivity
☐ Watery eyes
☐ Dry eyes
☐ Red eyes
☐ Scratchy, itchy eyes
☐ Headaches
☐ Floaters
For distance viewing, you mostly wear:
☐ Double vision
☐ Eyeglasses
☐ Poor night vision / Glare Problems
☐ Contact Lenses
☐ Nothing
Rate the quality of your distance vision with your current distance prescription:
For near viewing, you mostly wear:
☐ Eyeglasses
☐ Contact Lenses
Rate the quality of your near vision with your current near prescription:
For computer viewing, you mostly wear:
☐ Eyeglasses
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☐ Nothing
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☐ Contact Lenses
☐ Nothing
Rate the quality of your computer vision with your current computer prescription:
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Computer Demands: Please check all that apply.
☐ Desktop
☐ Laptop
☐ iPad / Tablet
☐ Smart Phone
☐ Multiple screens
List total hours per day you are looking at these devices.
Work # hours Click here to enter text.
Home # hours Click here to enter text.
School # hours Click here to enter text.
Are your sunglasses:
☐ Prescription
☐ Non-Prescription
% of time you wear sunglasses when you are DRVING:
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% of time you wear sunglasses when you are OUTDOORS:
Are you interested in getting LASIK VISION SURGERY? :
☐ I do not wear sunglasses
☐ Yes
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☐ No
When:
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Purchase Plans for this visit (check all that apply):
☐ New Eyeglasses
☐ Prescription Sunglasses
☐ Non Prescription Sunglasses
☐ Computer glasses
☐ Reading glasses
☐ Sports glasses for Click here to enter text.
☐ Supply of Contacts
☐ Vitamins
☐ Therapeutic Eye Mask
☐ Moisture tears
☐ Eyelid Scrub Foam
☐ Other Click here to enter text.
Systemic Health (check all that apply): ☐ NONE
Constitution
☐ Developmental Disability
☐ Cancer
☐ Fatigue / Weakness
Ear – Nose - Thoat
☐ Hearing Loss
☐ Sinusitis
☐ Dry Mouth
☐ Laryngitis / Throat problems
Neurological
☐ Multiple Sclerosis
☐ Epilepsy
☐ Cerebral Palsy
☐ Stroke / CVA
☐ Migraines
☐ Autism
Psychological
☐ Depression
☐ ADD / ADHD
☐ Anxiety
☐ Bipolar
Cardiovascular
☐ High Blood Pressure
☐ Heart Disease
☐ Vascular Disease
☐ Congestive Heart Failure
☐ Heart Attack
Respiratory
☐ Asthma
☐ Bronchitis
☐ Emphysema
☐ COPD
☐ Sleep Apnea
Gastro-intestinal
☐ Crohn’s
☐ Colitis
☐ Ulcers
☐ Acid Reflux
☐ Celiac’s
Genitourinary
☐ Kidney Disease
☐ Prostrate disease / Cancer
☐ STD- Herpes / Chlamydia
☐ Pregnant / Nursing
Muscular-skeletal
☐ Arthritis
☐ Fibromyalgia
☐ Osteoporosis
☐ Gout
Integumentary
☐ Eczema
☐ Rosacea
☐ Psoriasis
☐ Cold Sores
☐ Shingles
Endocrine
☐ Diabetes – Type 1
☐ Diabetes – Type 2
☐ Thyroid Dysfunction
☐ Hormonal / Menopause
Hematological
☐ Anemia
☐ High Cholesterol
Immunological
☐ Rheumatoid Arthritis
☐ Lupus
☐ Sjogrens disease
Any Additional Health Problems: Click here to enter text.
List all Medications (include Prescriptions, Vitamins and Over-the-counter): ☐ NONE
Oral medication:
Eyedrops:
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List all Allergies: ☐ NONE
Medication allergies:
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Environmental allergies:
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List all past Eye Problems, Eye Injuries, Eye diseases or Conditions: ☐ NONE
List all past Surgeries of any kind and date of procedure: ☐ NONE
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Social History:
Smoking:
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Drinking:
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Exercise:
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Family History (check all that apply and list relationship of family member. (Father, Mother, Sister, Brother,
Grandfather, Grandmother, Aunt, Uncle)
☐ Glaucoma: Click here to enter text.
☐ Macular Degeneration:
☐ Cataract:
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☐ Retinal Detachment:
☐ Lazy Eye / Eye Turn:
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☐ Colorblind:
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☐ Blindness:
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☐ Diabetes:
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☐ High Blood Pressure:
☐ Cholesterol:
☐ Heart Disease:
☐ Stroke:
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☐ Thyroid:
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☐ Arthritis:
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☐ Cancer:
☐ Other:
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☐ NONE
☐ UNKNOWN : Click here to enter text.