About
Technology
New Patients
Contact
About
Technology
New Patients
Contact
Please take a moment to fill out the following form prior to your visit, thank you.
Which office do you plan to visit?
Auburn
Augusta
Bangor
South Portland
Name
First Name
Last Name
DOB
MM
DD
YYYY
Today's Date
MM
DD
YYYY
Reason for appointment
Do you wear glasses?
Yes
No
If yes, are they for
Distance
Near
Both
If yes, what type of glasses
Single Vision
Bi-focal
Progressive
Tri-focal
Do you wear contacts?
Yes
No
If yes
Daily wear
Extended wear
How often to you replace your lenses?
Do you have glaucoma?
Yes
No
If yes, how is it being treated?
Have you ever had cataract surgery?
Yes
No
If yes, when?
MM
DD
YYYY
Other eye surgeries or eye diseases?
Yes
No
If yes, what?
When?
MM
DD
YYYY
Last eye exam was on
MM
DD
YYYY
What did the doctor tell you about your eyes?
Medical Doctor's name
First Name
Last Name
Medical Doctor's address
Were you born prematurely?
Yes
No
If yes, how early?
Have you ever suffered from any of the following?
Please check all that apply
Headaches, sinus, or tonsillectomy
History of psychological disorder(s)
Heart condition
Thyroid disease
High blood pressure
Diabetes
Circulatory problems
Bleeding disorder
Kidney, bladder, or prostate disease
Ulcers, liver, or gallbladder
High cholesterol
Smoke cigarettes
Seizures
Stroke
Lung disease
Cancer
Anemia
AIDS/Infectious disease
Any other diseases not mentioned above?
List of medications
Family history
Please check all that apply
Cataracts
Retinal disease
Glaucoma
Hypertension
Diabetes
Anemia
Age related macular degeneration
Retinitis Pigmentosa
Toxoplasmosis
Other
If other, please list
Thank you!
