Lifetime Eye Care Online Form

Please fill out all information below as completely as possible. Be sure to click the "Submit Data" button at the bottom when finished to securely submit the form.

Returning Patient? If you've had an exam with us in the last 2 years, you can use our Short Update Form
Having trouble? Call/Text 480-706-3060 or Email office@azlifetime.com

Patient Information

Ocular History

During the Last 3 Months, what ocular symptoms have you experienced?

  • Blurry Vision

  • Double Vision

  • Flashes

  • Floaters

  • Dry/Gritty Eyes

  • Itchy Eyes

  • Watery Eyes

  • Painful/Sore Eyes

  • Tired Eyes

  • Light Sensitivity

  • Red Eyes

  • Mucous/Crusty Eyes

  • Crossed/Lazy Eye

  • Other Ocular Symptoms:

  • No ocular symptoms recently



Estimate your Average Hours Per Day on the following screens:

  • Desktop Monitor

  • Laptop Screen

  • Tablet/Phone




Have you ever been diagnosed with any of these Systemic Conditions that can affect the Eyes?

  • Diabetes

  • Hypertension

  • Cancer

  • High Cholesterol

  • Thyroid Problems

  • Lupus

  • Sarcoidosis

  • Sjogrens Syndrome

  • Rheumatoid Arthritis

  • Multiple Sclerosis

  • Notes:

  • None of these systemic conditions

Medical History


  • Pregnant
  • Nursing
  • No current health issues



  • No
  • Yes (please describe):

  • No
  • Yes (please describe):


Please check if you have ever had significant problems with the following systems:

  • Allergic/Immunologic

  • Cardiovascular

  • Constitutional

  • Ear/Nose/Mouth/Throat

  • Endocrine

  • Gastrointestinal

  • Genitourinary

  • Hematologic/Lymphatic

  • Integumentary

  • Musculoskeletal

  • Neurological

  • Psychiatric

  • Respiratory

Family History

Family Ocular History:

Please mark if your family has had any history of eye diseases or problems (and notate their relationship to you):


  • Cataracts

  • Glaucoma

  • Macular Degeneration

  • Retinitis Pigmentosa

  • Strabismus/Lazy Eye

  • Other:

  • No family history of ocular problems

  • Unknown family history


Family Medical History:

Please mark if your family has had any history of major health problems (and notate their relationship to you):


  • Diabetes

  • Hypertension

  • Heart Disease

  • Thyroid Disease

  • Cancer

  • Other:

  • No family history of major medical problems

  • Unknown family history

Submit

Please complete all sections, then click the green button above for your information to be securely sent to us. Thank you!