Armstrongandsmall.com

NEW PATIENT
QUESTIONNAIRE
In order for us to better serve the needs of our new patients, we would
appreciate a brief health history to assist in the examination.

Name: _____________________________ Occupation: _______________________________
E-mail: _________________________________________________________________________
How did you hear about us : ______________________________________________________
Reason for visit (please check appropriate options):

Personal Medical History:
Have you been treated for any one of the following medical conditions?
___ Diabetes (Type 1) ___ Diabetes (Type 2) ___ Hypertension (High Blood Pressure)
___ High Cholesterol ___ Thyroid
___ Atherosclerosis ___ Rheumatoid Arthritis Other: ________________________________________________________________________ Are you currently taking any medications? ___ Baby Aspirin ___ Hydro Chlorothiazide Other(s): ______________________________________________________________________ Allergies to medications? Y / N If yes, then which?_______________________________ Allergies in general? Y / N If yes, then to what? _________________________________ Do you smoke? Y / N When was your last visit to your family physician? ___ Less than 1 yr Name of family physician:_____________________________________________________
Personal Ocular History:
When was your last visit to an optometrist?
___ Less than 1 yr
Name of optometrist: _________________________________________________________ Do you use a computer on a daily basis? Y /N ___Never Have you ever worn / are you wearing contact lenses? Y / N What brand? ________________________________________________________________ Type of contact lens solution used? _____________________________________________ Any history of infections/inflammation secondary to CL wear? Y / N Have you ever had eye surgery? Y / N If yes then what type? What was the name of the eye surgeon who performed your surgery?_______________ Have you ever had an eye injury? Y / N If yes, please describe: ____________________ _____________________________________________________________________________ Have you or a family member had any of the following eye problems/disease? ____Glaucoma ____Retinal Detachment
Please specify who it is with the disease: _________________________________________
Visual Needs (please check appropriate options):
___ Work at a computer for long periods of time?
___ Have more than one pair of glasses
___ Want information on thinner, lighter lenses?
___ Wear bifocals or progressives?
___ Prefer not to wear glasses at certain times?
___ Spend a lot of time outdoors
___ Ever find a need for prescription sunglasses?
___ Have problems with glare or reflections (e.g. night driving, computer work)?
___ Do work requiring safety glasses
___ Participate in sport activities? What? __________________________________
___ Want more information about corrective vision surgery?
___ Wear or ever tried wearing contacts? What kind?________________________
___ Interested in coloured contact lenses? Full time? Part time?
DISCLOSURE NOTICE:
All above information is for office use only and will not be used for any other purpose.

Source: http://www.armstrongandsmall.com/pdf/new-patient.pdf