Welcome New Patients!

At A to Z Eye Care, we are always excited to meet new patients during their first visit to our Arcata optometry office. Our team will do everything they can to ensure that your first visit is friendly, comfortable, and leaves you feeling confident about your eyes. We help children and adults maintain healthy eyesight in the surrounding areas of Arcata. In order for us to get to know you better, please submit the following form.
Complete Your Personal Information
Salutation

Last Name

First Name

Middle Initial

Address

State

City

ZIP

ft

cm
in

m
lbs
kg


Complete Your Health History
Enter past illnesses or injuries

Past surgeries

Please list all medications or provide a list to the doctor



Please list all eye drops you are currently using



Please list any reactions or sensitivities you have experienced



Please list any specific allergies



Complete Your Eye History
Glaucoma
Infection of Lid

Cataract
Itching

Macular Degeneration
Mucuous Discharge

Retinal Detachment
Drooping Eyelid

Color Blindness
Redness

Headaches
Sandy or Gritty Feeling

Glare/Light Sensitivity
Blurred Vision Distance

Tired Eyes
Blurred Vision Near

Lazy Eyes
Crosed eyes

Burning
Distorted Vision (halos)

Dryness
Double Vision

Excess Tearing/Watering
Floaters or Spots

Eye Pain or Soreness
Fluctuating Vision

Foreign Body Sensation
Loss of Vision

Loss of Side Vision

Complete Your General Health Conditions
Fever
Muscles/Bones/Joints

Weight Loss
Skin

Other Symptoms
Neurological

Ears/Nose/Throat
Anxiety or Depression

Heart conditions
Thyroid/Diabetes

Respiratory (i.e. Asthma)
Blood/Lymph (cholesterol)

Gastrointestinal
Allergic

Kidney

Are you...

Complete Your Family History
Ambylopia (Lazy Eye)
Cancer

Blindness
Diabetes

Cararact(s)
Heart Disease

Color Blindness
High Blood Pressure

Glaucoma
Kidney Disease

Macular Degeneration
Lupus

Retinal Detachment
Stroke

Strabismus (i.e. Eye Turn)
Thyroid Disease

Arthritis
Others


Complete Your Spectacle Lens History
Do you use a computer?

How many hours/days?

Distance from computer

Do you currently wear glasses?
Since?

Type of glasses?


Complete Your Contact Lens History
Do you currently wear contact lenses?
Since?

Type and brand of contacts


Thank you for completing the Welcome Form information, we will be able to provide you with the best evaluation of your health using this information. We look forward to seeing you soon!

Print Form

Contact Your Arcata Optometrists

If you have any difficulty with completing our online form, please call our optometry office at 707.822.7641 and our staff will be happy to assist you. If you have any other questions about your vision and the services we provide that you would like answered before your first appointment, please feel free to contact us. The A to Z Eye Care team looks forward to meeting you, and look forward to providing you with the most advanced and effective eye care available!