Vision & Ocular History

About this form

The vision & ocular history is a medical history document used by optometry practices. Comprehensive vision and ocular health history including family eye disease. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 11 fields:

• Patient Name — Text
• Vision concerns — Long answer
• Symptoms — Multiple choice
• Family eye disease history (glaucoma, macular degeneration, etc.) — Long answer
• History of eye surgery? — Single choice
• Current medications — Long answer
• Diabetic? — Single choice
• High blood pressure? — Single choice
• Other relevant medical history — Long answer
• Signature — Signature
• Date — Date

When practices use it

Optometry teams typically attach this form to the pre-treatment review, so the provider can read the patient's history before the visit. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.