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General Adult Questionnaire

Please carefully complete our questionnaire. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your visual system related to your specific needs.

General Information

Please check one of the following:

Patient History

Vision History

Contact Lens Policy: If you are requesting a contact lens prescription, our office provides a full service program – evaluation, fitting, and follow-up. Our office does not release the contact lens prescription until you have been successfully evaluated and fitted.

Review of Systems

Do you currently, or have you ever had any problems in the following areas? If you do, please explain.


Ears, Nose, Mouth, and Throat




Bones, Joints, and Muscles

Lymphatic and Hematologic

Family History

If anyone in the family (grandparents, uncles, aunts, cousins, mother, father, and/or siblings) has any of the following conditions, please indicate who. If not applicable, please leave it blank.