Optometry Intake template
An optometry intake form covering what the exam room asks anyway: visit reason, current prescription, date of the last exam, a symptom checklist from blurry distance vision to night-driving glare, and family history of glaucoma, macular degeneration, cataracts, and diabetic eye disease. Patients who wear no correction skip the prescription question entirely.
11 questions · works on the free plan (500 responses/month) · fully customizable
- 1 built-in logic rule
What’s inside
The questions this template ships with — rename, reorder, or delete any of them in the builder.
When to use this template
- An independent optometry practice sending intake with appointment reminders so the pre-test runs on schedule
- An optical chain collecting family history ahead of the exam, where glaucoma and macular degeneration change what gets tested
- A contact lens fitting service that needs current prescription details before the appointment
- A practice seeing lapsed patients, where the last-exam date sets the scope of the first appointment back
Tips to get more from it
- The prescription question is hidden by a skip rule for patients who wear neither glasses nor contacts, and its description tells everyone else to copy it from their card or lens box — precision the patient can actually supply
- The symptom checklist runs in a two-column grid and allows Other; the family-history checklist includes both "None of these" and "Not sure," which is the honest option most patients need
- The ending reminds patients to bring current glasses or lenses and sunglasses in case of dilation. That one line prevents a lot of squinting in the parking lot
- Zunoform offers no HIPAA Business Associate Agreement, so use this to prepare for the visit and keep the clinical record in your practice management system
Questions people ask
What information should an eye exam intake form collect?
Visit reason, whether the patient wears correction and their current prescription, last exam date, current symptoms, and family history of eye disease. This template asks all of those in eleven fields, with one skip rule for patients who wear no correction.
Why does the form ask about family eye history?
Glaucoma, macular degeneration, cataracts, and diabetic eye disease all run in families, and knowing that in advance changes what the optometrist looks for. The checklist includes "Not sure" so nobody has to guess.
Is the optometry intake template free?
Yes. Every field in it publishes on the free plan — unlimited forms and 500 responses per month, no card required.
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