..:: Appointment ::..

Monday

1pm

3pm

5pm

Wednesday

12pm

2pm

4pm

Friday

9am

10am

11am
  • Online: www.bascomoptometry.com
  • Email: bascomoptometry@sbcglobal.net
  • Phone: (408) 222-2020

PATIENT INFORMATION FORM
To expedite your service, please print, fill out, and bring this form to the exam with you
or email this form to: bascomoptometry@sbcglobal.net prior to your appointment time.

Patient Name:

 

Birthdate:

 

Occupation:

 

Gender:

Male  qFemale

Type of Exam:

Glasses

Contact Lens Spherical

Contact Lens Toric

Contact Lens Monovision

Contact Lens RGP

No Glasses/CL

Chief
Complaint:

Distance Blur

Computer Blur

Near Blur

Eye Pain

Eyestrain

Light Sensitive

Red Eyes

Dry Eyes

Flashes

Floaters

Partial Vision Loss

Transient Vision Loss

Total Vision Loss

Dimming Vision

Double Vision

Systemic Diseases

Personal

Family

Medication Currently Taken

Diabetes

Yes  No

Yes  No

 

High Blood Pressure

Yes  No

Yes  No

 

Cholesterol

Yes  No

Yes  No

 

Heart

Yes  No

Yes  No

 

Cancer

Yes  No

Yes  No

 

Thyroid

Yes  No

Yes  No

 

Allergies

Yes  No

Yes  No

 

Skin

Yes  No

Yes  No

 

Ocular Diseases

Personal

Family

Medication Currently Taken

Glaucoma

Yes  No

Yes  No

 

Macular Degeneration

Yes  No

Yes  No

 

Cataract

Yes  No

Yes  No

 

Diabetic Retinopathy

Yes  No

Yes  No

 

Optic Neuritis

Yes  No

Yes  No

 

Eye Surgery

Yes  No

Yes  No

LASIK 
Cataract   
Strabismus  Other

Eye Injury

Yes No

Yes  No

 

Amblyopia (lazy eye)

Yes  No

Yes  No