Skip to content
304-636-9111
1500 Harrison Avenue, Elkins, WV
Mon. - Fri. • 8:30 am - 5:00 pm
A
Decrease font size.
A
Reset font size.
A
Increase font size.
Home
Services
Vision Examinations
Adult Well Vision Examinations
Child Well Vision Examinations
Infant Well Vision Examinations
Medical Vision Examinations
Back To School
Vision Correction Services
Custom Eyeglasses – Frame Fittings
Specialty Lens Consultation
Contact Lens Examinations
Lasik Eye Surgery
Medical Eye Care
Urgent Medical Eye Care
Diabetic Eye Care
Glaucoma
Cataracts
Pediatric Vision & Eye Care
Senior Vision & Eye Care
Emergency Eye Care
About Us
Fees, Payment, Insurance
Meet Dr. Craig
Why Choose Dr. Craig
News
Testimonials
Patient Resources
Eye Care for You
Arthritis and Your Eyes
Be Safe and Be Seen this Halloween
Christmas Gift Certificates
Think You Save Buying Contact Lenses Online?
National Glaucoma Awareness Month
RGP Contact Lens That Feels Like a Soft Lens
Safety Tips for Hunters
Say NO to Novelty Contact Lenses
Sunglasses
To Custom or Not to Custom, That Is the Question
Vision Abnormalities & Eye Issues Glossary
Age-related Farsightedness (Presbyopia)
“Blurry Near & Far Vision” (Astigmatism)
Cataracts
“Color Blindness” (Color Vision Deficiency)
Computer Vision Syndrome
“Crossed Eye” (Strabismus)
Diabetic Retinopathy
Dry Eye
Eye Allergies (Ocular Allergies)
Farsightedness (Hyperopia)
Floaters & Spots
Glaucoma
“Lazy Eye” (Amblyopia)
Vision-related Learning Problems
Macular Degeneration
Nearsightedness (Myopia)
Ocular Hypertension
Ocular Migraine (Visual Aura)
“Outward Eye Drift” (Convergence Insufficiency)
“Pink Eye” (Conjunctivitis)
Dr. Craig’s Video Series
Vision Direct
Blind and Visually Impaired (Access Help)
Forms
Contact Us
Patient Medical History
NOTE: PLEASE DO NOT LEAVE ANY AREAS BLANK. IF A QUESTIONS DOES NOT PERTAIN TO YOU PLEASE PUT N/A (Not Applicable)
Date
(Required)
MM slash DD slash YYYY
Name
(Required)
First
Last
Nick Name
(Required)
MEDICAL HISTORY (ANY PAST/ CURRENT MEDICAL CONDITIONS)
(Required)
SURGICAL HISTORY (SURGERY, INCLUDING COMPLICATIONS, TRAUMA)
(Required)
CURRENT MEDICATIONS AND DOSAGE
(Required)
MEDICATION ALLERGIES/ REACTIONS
(Required)
LAST WELL VISION EXAMINATION?
Doctor
(Required)
Where
(Required)
When
(Required)
Primary Physician
(Required)
Primary Physician Phone
(Required)
FAMILY MEDICAL HISTORY (ESPECIALLY PARENTS AND SIBLINGS)
(Required)
EYE SURGERIES
(Required)
FAMILY EYE HISTORY (GLASSES, CONTACTS, SURGERIES)
(Required)
DO YOU CURRENTLY SMOKE, USE ALCOHOL OR DRUGS?
(Required)
Do You...
Currently wear glasses?
(Required)
Yes
No
Wear Progressive Lenses?
(Required)
Yes
No
Any concerns with glasses?
(Required)
Yes
No
Have a backup pair of glasses?
(Required)
Yes
No
Have concerns with glare?
(Required)
Yes
No
Have concerns with scratches?
(Required)
Yes
No
Have concerns with wearing sunglasses?
(Required)
Yes
No
Are you interested in knowing about contact lenses?
(Required)
Yes
No
Currently wear contact lenses?
(Required)
Yes
No
Mono vision?
(Required)
Yes
No
Bifocal?
(Required)
Yes
No
Replacement frequency?
(Required)
New Patients Only - to whom may we thank for referring you to the Family Eye Care Center?
(Required)
If not referred, how did you find out about Family Eye Care?
(Required)
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Δ
