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Note: Do not use this form for an emergency!
Patient Information
First:     Last: 
Address: 
 
City:     State: 
Zip Code: 
Home Telephone:     Ext.  
Cell Number: 
Email Address: 
 
Date of Birth:  Month:  Day:  Year: 
Sex: 
Social Security No.: 
Marital Status: 
Currently Employed: 
Referring Optometrist (If Applicable)
First:     Last: 
Phone Number: 
Emergency Contact
First:     Last: 
Home Phone Number: 
Work Phone Number: 
Relationship to Patient: 
Primary Care Physician
First:     Last: 
Address: 
 
City:     State: 
Zip Code: 
Phone Number: 
Insurance Information
Insurer: 
Policy No.:     Group No.: 
Is insurance in your name?   
Is there secondary insurance?   
Do you have a history of: (select Yes or No)
High Blood Pressure: Stroke: 
Anemia/Sickle Cell: Cancer: 
Diabetes: Heart Attack/Angina: 
Thyroid Disease: Asthma/Emphysema: 
Kidney Disease/Stones: Psychiatric Problems: 
Other: 
Have you ever had any major surgery or hospitalization?   
Have you had any of the following eye problems: (select Yes or No)
Glaucoma: Cataracts: 
Blindness: Retinal Disease: 
Corneal Disease: Other: 
Any Family History of: (select Yes or No)
Cataracts: 
Glaucoma: 
Other: 
Please List All Eye Medications You Currently Take, Along with How Often and Dosage:
Left Eye: 
Right Eye: 
Medications
Insulin: 
Coumadin: 
Cortisone: 
Aspirin: 
Flomax: 
Specify any other medications along with their dosage and frequency:
Allergy Information
Do you have any known medicine allergies? 
Do you have any other allergies? 
Have you ever been exposed to any of the following infectious diseases:
(select Yes or No)
Hepatitis: AIDS: 
Tuberculosis:  
 
Do you have any bleeding problems or blood abnormalities?   
Have you had any prior problems with local or general anesthesia?   
Do you have any health problems, medication, or allergies not mentioned above?   
Social History
Are you still working? 
Are you pregnant? 
Weight Status: 
Are you currently driving? 
How often do you exercise? 
How often do you consume alcohol? 
Are you a smoker? 
Review of Systems

Are you currently experiencing any of the following problems:
Chronic Fever: 
Unexpected Weight Loss or Gain: 
Fatigue: 
Ear/Nose/Throat Problems: 
(Hearing/Sinus/Sore Throat)
Heart Problems: 
(Chest Paint/Irregular Heartbeat)
Respiratory Problems: 
(Shortness of Breath/Wheezing/Coughing)
Gastrointestinal Problems: 
Urinary Problems: 
Skin Problems: 
Musculoskeletal Problems: 
Neurological Problems: 
Blood Disorders: 
Psychiatric Problems: 
Visual Function Questionnaire

With Glasses

Please answer all questions to the best of your ability (Yes or No):
Can you see things clearly across the room? 
Can you see things clearly across the street during the day? 
Can you see things clearly across the street at dusk? 
Can you see colors clearly? 
Can you do close work comfortably outside during the day? 
Can you do close work comfortably in dim light? 
Please rate the difficulty of doing each of the following (in terms of sight):
Moving about your home: 
How Long: 
Moving about in unfamiliar places: 
How Long: 
Reading the newspaper: 
How Long: 
Reading labels: 
How Long: 
Recognizing people: 
How Long: 
Watching television: 
How Long: 
Writing letters: 
How Long: 
Reading traffic signs: 
How Long: 
Reading prices: 
How Long: 
Seeing steps: 
How Long: 
Seeing in dim light: 
How Long: 
Reading books: 
How Long: 
Seeing cracks in the sidewalk: 
How Long: 
Playing card and/or board games: 
How Long: 
Perceiving depth: 
(e.g. parallel parking, pouring coffee)
How Long: 
Lifestyle Questionnaire
Does wearing glasses bother or frustrate you? 
Are you interested in surgery to reduce your need for glasses? 
Would it bother you to wear glasses for some tasks after surgery? 
Do you do a lot of night driving? 
Do you notice halos or glare around lights while driving at night? 
Would halos or glare around lights at night bother you after surgery? 
Do you use a computer on a daily basis? 
Do you do a lot of close detail work? 
Have you ever tried monovision contact lenses? 
Would you like to have, without glasses, good distance vision during the day, and good near vision for reading in good light, even if you might see some halos or glare around lights at night?
How would you describe your personality? 
 
  
 
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Dr. Richard S. Witlin, M.D., serving the state of New Jersey, including East Brunswick, Toms River, Morristown,
Livingston, Chatham, Freehold, Marlboro, Matawan, and Cranbury.

East Brunswick: 557 Cranbury Road, Suite 15 - East Brunswick, NJ 08816 - Phone: 732-698-9300
Toms River: 501 Lakehurst Road - Toms River, NJ 08755 - Phone: 732-341-9696
Morristown: 21 Perry Street - Morristown, NJ 07960 - Phone: 973-285-9300

Copyright © 2008 The Witlin Center for Advanced Eyecare  All Rights Reserved.