Delta Eye Care Patient Forms
Patient information
First Name
*This field is required
Last Name
*This field is required
Nickname
Address
Apt/Suite #
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code
Home Phone
Birthday (MM/DD/YYYY)
*This field is required
Email *For Online Portal Access
*This field is required
Occupation or Employer
Gender
Male
Female
Marital Status
Annulled
Divorced
Domestic partner
Legally Separated
Married
Never Married
Widowed
Please choose from the dropdown options or type in your own text. Thank you!
Vision History
What is the main reason for your visit today?
When was your last eye exam?
Unknown
First
Childhood
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2012
2011
2010
Type in your own text
What is your primary vision correction?
Nothing
Glasses
Contacts
Glasses 50/ Contacts 50
Type in your own text
Do you wear contacts?
No, not interested
No, but interested
Yes, not interested today
Yes, interested today
Type in your own text
When was the last time your eyes were dilated with dilation eye drops?
Unknown
Never
Childhood
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2012
2011
2010
Type in your own text
Please list any previous injuries, surgeries, disease or conditions. (Include dates)
Please list all current eye medications or eye drops.
Medical History
Primary Care Physician and/or Doctor Managing Diabetes
Do you have any of the following medical conditions?
Diabetes
Yes
No
Type in your own text
If yes, what was your last hemoglobin A1c?
High Blood Pressure
Yes
No
Type in your own text
High Cholesterol
Yes
No
Type in your own text
Thyroid Conditions
Yes
No
Type in your own text
Heart Conditions
Yes
No
Type in your own text
Cancer
Yes
No
Type in your own text
Autoimmune Disease
Yes
No
Type in your own text
Please list any other medical conditions:
Please list all current medications:
No current medications
Please list any drug allergies
No known drug allergies
Are you currently pregnant or nursing?
Yes
No
Unsure
Do you currently smoke cigarettes?
Never smoked
Former smoker
Currently smoke everyday
Currently smoke, but not daily
Alcohol Use
No
Yes, less than 7 drinks per week
Yes, more than 7 drinks per week
Type in your own text
Recreational Drug Use
No
Yes
Type in your own text
Family Eye History
Does anyone in your family have any of these eye conditions?
Macular Degeneration
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Glaucoma
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Retinal Detachment
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Keratoconus
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Cataracts
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Crossed / Lazy Eye
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Other eye conditions:
Family Medical History
Does anyone in your family have any of these medical conditions?
Diabetes
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Heart Conditions
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
Cancer
None
Unknown
Mom
Dad
Siblings
Maternal Grandparent
Paternal Grandparent
Other
For all new patients, please bring your latest glasses or contact lens prescription to your appointment or email it to
hello@deltaeyecaretx.com
Please make sure to submit your data when completed. Thank you!
Submit Data