New Patient Eye Exam Form
What a new patient eye exam form asks, with sample questions on eye history, medicines, and family eye disease.
A new patient eye exam form records the visit reason, eye problems and surgeries, medicines, general health, and family eye history before a first exam. It's also called a patient history questionnaire.
New patient eye exam form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a new patient eye exam form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample new patient eye exam form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- What is the reason for today's eye exam?Visit details
- When was your last eye exam?Visit details
- Is your vision blurred or does it fluctuate?Eye history
- Have you had any eye surgery or laser treatment?Eye history
- Which medicines and eye drops do you take?Medications
- Are you allergic to any medications?Medications
- Do you have diabetes or high blood pressure?Medical history
- What other surgeries have you had?Medical history
- Has anyone in your family had glaucoma?Family history
- Does macular degeneration run in your family?Family history
- Do you wear glasses or contact lenses?Daily vision
- Do you have trouble seeing when driving?Daily vision
These are examples to read, not a form to fill in.
New patient eye exam form: FAQ
What does a new patient eye exam form ask?
The sample questions on this page are based on the ophthalmology history forms of SUNY Downstate and Ohio State Wexner Medical Center. This page groups them into six areas: visit details, eye history, medications, medical history, family history, and daily vision.
Who fills in a new patient eye exam form, and when?
The patient, before the first exam. Ohio State asks new patients to hand in the completed questionnaire at check-in, together with an ID and an insurance card.
Does it include registration details?
It can. SUNY Downstate's Medical History Questionnaire covers health history only, while one practice pairs its history questionnaire with a registration form for contact and insurance details.
Does it ask about general health, not only the eyes?
Yes. The SUNY Downstate form goes through body systems such as the heart, lungs, skin, and joints, and endocrine conditions such as diabetes or thyroid disease.
Is there a template for an eye exam history form?
SUNY Downstate and Ohio State publish their forms as PDFs. The sample questions on this page show a typical set.
What happens after the new patient eye exam form is completed?
The practice's team reviews the answers before the exam. The SUNY Downstate form ends with a line where the physician marks the history as reviewed, with or without changes.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
