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We Can Change The Way You See Your World!

Please fill out and submit this form to learn more about MidWest EyeCenter and receive an
e-brochure on either Premium Lenses, Cataract Surgery or Laser Vision Correction.

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Our Locations

East: Eastgate Professional Building
Suite 305
4452 Eastgate Blvd
Cincinnati, OH 45245
513.752.5700 Map It
West: 6779 Colerain Ave.
Cincinnati, OH 45239
513.741.1313 Map It
North: 8760 Union Centre Blvd.
West Chester, OH 45069
513.454.0544 Map It
South: 7510 US Route 42
Florence, KY 41042
859.525.6215 Map It

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Eye History Form

Either fill out this online form below, or download and fill out the Eye History Form (PDF), and bring it with you on your next visit with us.

Patient Name*

Date*

Who performed your most recent eye exam?

Why are you being seen today?

Have you discussed refractive or cataract surgery with your previous doctor?

Yes

If you are having a surgical procedure, are you planning to see your previous eye care provider for your post-op care?

Yes

My glasses were perscribed by Dr.

How old are your glasses?

Do you wear contact lenses?

What type of lens?

Soft

Hard

Rigid Gas Permeable

Disposable

Daily Wear

Extended Wear

Do you have trouble with distance vision?

With glasses?

Yes

Without glasses?

Yes

Do you have trouble with near vision?

With glasses?

Yes

Without glasses?

Yes

Do you have trouble with

Bright lights or night vision?

Yes

Distorted vision?

Yes

Mucous Discharge?

Yes

Redness?

Yes

Itching, burning or tearing?

Yes

Eye pain?

Yes

Floaters?

Yes

Have you ever been treated for any of the following:

Cataracts

Yes

Glaucoma

Yes

Strabimus or lazy eye

Yes

Retina disease

Yes

Have you ever had surgery or laser treatments to your eyes?

Yes

The names of all the eye drops that you use are:

Are you allergic to any medications?

Please list all medications that you take

Your family doctor is Dr.

Address

City

State

Zip

Doctors Phone #

Are you under the care of a cardiologist?

Yes

If yes, please list your cardiologist

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Disclaimer: This site contains information about eye surgery and procedures related to eye care. It is not to be taken as medical advice.