Optical Patient Intake Form

Optical Patient Intake Form — Form Fields

This healthcare template includes 8 fields across 2 pages. Collect patient information and vision history for optometry appointments. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Email Address (email, optional)
• Do you currently wear corrective lenses? (multiple choice, required) — options: Glasses, Contact lenses, Both, Neither
• Current Vision Concerns (checkboxes, optional) — options: Blurry vision, Eye strain / headaches, Dry eyes, Sensitivity to light, Floaters or flashes, None — Select all that apply.
• Last Eye Exam (dropdown selection, required) — options: Within the last year, 1-2 years ago, 3+ years ago, Never had one
• Other Medical Conditions (long text, optional) — These can affect eye health.