New Patients

Metropolitan Optical

Marital Status:

How did you hear about Metropolitan Optical? (Check which applies)

Are you planning on purchasing glasses and/or contacts?

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EYE CARE NEEDS

Check any of the following you have had:

Do you wear glasses?

Do you wear contact lenses?

Type of contact lenses:

Are they comfortable?

Have you had LASIK surgery?

Are you sensitive in bright sunlight?

Do you perform fine or close-up work?

Do you have trouble reading signs when driving at night?

Are you outdoors all or part of the time?

Are you bothered by the glare from overhead lighting?

Is safety protection a concern at work?

Are you bothered by the glare from a computer screen?

What hobbies or sports do you play?


Eyes

Loss of Vision

Burning

Blurred of Vision

Foreign Body Sensation

Distorted Vision

Excess Tearing / Watering

Loss of Side Vision

Glare / Light Sensitivity

Double Vision

Eye Pain or Soreness

Dryness

Chronic Infection of Eye / Lid

Mucous Discharge

Sty or Chalazion

Redness

Flashes / Floaters in Vision

Sandy or Gritty Feeling

Tired Eyes / Eye Strain

Itching

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MEDICAL HISTORY: Do you currently have, or do you have a family history of any of the following conditions?


Ocular History

Glaucoma

Retinal Detachment

Cataracts

Macular Degeneration

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Endocrine

Thyroid / Other Glands

Genitourinary

Genitals / Kidney / Bladder

Ears, Nose, Mouth, Throat

Allergies / Hay Fever

Sinus Congestion / Dry Throat or Mouth

Runny Nose / Chronic Cough

Bones / Joints / Muscles

Rheumatoid Arthritis

Muscle Pain / Joint Pain

Allergic / Immunologic

Respiratory

Asthma / Bronchitis

Chronic Bronchitis

Emphysema

Cancer

Skin (Integumentary)

Psychiatric

Vascular / Cardiovascular

Diabetes / Heart Pain

High Blood Pressure / Vascular Disease

Gastrointestinal

Neurological

Seizures

Headaches / Migraines

Are you currently pregnant or nursing?

HIPPA ACKNOWLEDGEMENT:

ASSIGNMENT OF BENEFITS:

none 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 2:00 PM Closed 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM 10:00 AM - 4:00 PM Closed Closed 1150 18th St. NW Washington DC 20036 2026596555