Returning Patients

Returning Patients

Returning Patients

Returning Patients

Returning Patients

Metropolitan Optical

Marital Status:*

Are you planning on purchasing glasses and/or contacts?*

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EYE CARE NEEDS

Do you wear contacts? *

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*

Are you currently pregnant or nursing?

HIPPA ACKNOWLEDGEMENT:

ASSIGNMENT OF BENEFITS:

Roya1234 none 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM Closed Closed 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM 8:30 AM - 5:00 PM Closed Closed 919 18th St. NW Washington DC 20006 2026596555