Patient Check In Form:
Select the Office you will be visiting
I will be visiting the Manchester Office.
I will be visiting the Merrimack Office.
Your Contact Details
Labels with a red
*
are required.
Patient Name
*
Occupation
Street Address
*
City
*
State
*
Zip Code
*
Day Phone
*
Home Phone
*
Email
*
Todays Date
*
Birth Date
*
Are you currently a Patient of Merrimack Vision Care?
Yes
No
Lifestyle Questions
Please select all that apply.
Biking
Skiing
Golf
Public Speaking
Tennis
Night Driving
Team Sports
Computer Use
Hiking
Boating
Gardening
Fishing
Visual Symptons
While wearing my current correctional lenses, I experience the following.
I don't wear any correctional lenses at this time and I experience the following.
I am bothered by blurry distance vision.
I am bothered by blurry close vision.
I have trouble viewing text on my computer.
I get double vision.
My eyes water or are bloodshot.
I have difficulty driving at night or in the rain.
I am visiting today for a routine eye exam.
I am visiting today for a contact lens exam.
I frequently experience headaches.
I experience floaters.
Medical / Visual History
Please select all that apply.
Cancer.
High Cholesterol.
Head Injury.
Heart Disease.
Diabetes.
Glaucoma.
Flashes of light.
Sudden loss of vision.
Eye Surgery.
High Blood Pressure.
Arthritis.
Family History of...
Macular Degeneration.
Diabetes.
Glaucoma.
Please list any medications you are taking.
Please list any allergies and/or drug sensitivities.
