Handel Vision Clinic
(330) 666-1766
contactus@handelvisionclinic.com
Arlington Eye Care
(330) 899-0202
contactus@arlingtoneyecare.com
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Welcome!
Please fill out this form completely as it will be helpful in providing you with better health and eye care. Thank you.
Which of our office locations are you visiting?
*
Arlington Eye Care- Green, Ohio
Handel Vision Clinic- Fairlawn, Ohio
Please contact me about making an appointment
Date
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MM
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Patient's Name
*
Prefix
First
Last
Suffix
Name of Responsible Adult
if Patient is a Minor:
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba,Bahamas
Barbados
Belize
Canada
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
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Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
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Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
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Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
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Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
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Portugal
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Japan
Jordan
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North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country
Daytime Phone
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Secondary Phone
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All cell phone numbers on your account will receive one text message from our office. At that time you may opt-in or out of receiveing future appointment reminders and notifications.
Email
Referred by
Date of Birth:
*
MM
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Age:
*
SS#
Patient's Occupation:
Student
Stay At Home Parent
Other
Hobbies
Wood Working
Fishing
Boating
Sport Shooting
Sewing/Needle Crafts
Motorcyclyes
Outdoor Activities
Sports
Golf
Running
Walking
Cycling
Skiing
Swimming
Baseball
Soccer
Football
Basketball
Last Exam:
MM
/
DD
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With
Dr. Handel
Dr. King
Dr. Nelson
Other
When do you wear glasses?
Always
For Distance
For Close Work
For Contact Lens Backup
Never
Are you satisfied with your vision at the present time?
Yes
No
Do you have frequent headaches?
Yes
No
Have you ever had any eye disease, eye injury, and/or eye surgery?
Yes
No
Describe:
Does any family member have an eye disease or disorder?
Yes
No
Describe:
Do you work at a computer terminal?
Yes
No
How many hours per day?
List any special visual demands (Occupational or Otherwise):
Have you ever worn contact lenses?
Yes
No
Are you interested in contact lenses?
Yes
No
Do you currently wear contact lenses?
Yes
No
What type?
Hours per day?
Age of lenses?
Are you interested in laser vision correction?
Yes
No
Do you or any family member have diabetes?
Yes
No
Who?
Do you have any medical problems?
Yes
No
Describe:
When was your last medical (physical) exam by a physician?
MM
/
DD
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Dr.
List any medications you are currently taking and the reason it was prescribed:
*
What tobacco products
do you use?
*
None
Cigarettes
Cigars
Smokeless Tobacco
Other
Frequency
Please check all that apply to you:
Dry Eyes
Eyes Itch
Eyes Burn
Red Eyes
Eyes Hurt
Double Vision
Eyes Tire
See Floaters
See Flashing Lights
Lazy Eye or Amblyopia
Eyes Turn In/Out
Computer Glare
Glare at Night
Sinus Problems
Difficulty Seeing At Night
None Of The Above
Allergies
No Known Allergies
Please List
Do you have Optical Insurance?
*
Yes
No
Who?
Do you have Medical Insurance?
*
Yes
No
Who?
Method of Payment:
Cash
Check
Credit Card
Care Credit
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