Patient questionnaire

patient-questionnaire

Name

Email

Please write your gender below. Phone number Are you experiencing any symptoms of COVID(fever, cough, shortness of breath) OR been exposed to others in last two weeks who have*
If yes please describe below or type no. Reason for visit?
Please type your answer below. —routine exam —eye infection —contact lens evaluation Current meds
Please type your answer below . Allergies to medications? (y/n)
if yes then name the medications Wear eye glasses (y/n)
Please type your answer below. —if yes for distance, near, or both Wear contacts (y/n)
Please type your answer below. If yes then name brand and if possible Rx Personal Eye History
Please type your answer below. —surgery (y/n) if yes name type of surgery —trauma (y/n) Family history eye disease (y/n)
if yes then name disease
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