Clinical · free template

Eye Exam Intake Form

Pre-exam optometry intake: recent vision changes, current glasses or lenses, screen and driving needs, eye history, and relevant general health.

A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 17 questions, 2 pages, 3 conditional rules.

Questions: 17
Pages: 2
Layouts: classic · card
Time to complete: ≈ 5 min
Conditional rules: 3

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Patient intake

Compliance checklist

Ready to publish

Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Eye Exam Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.

Small teams who need a reliable intake process working in healthcare & clinical.
Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
Anyone replacing chasing missing details over email with one structured record per enquiry.
Respondents are the people you send it to — the form asks them 17 questions across 2 screens.
Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.

9 questions are required, so submissions arrive complete instead of needing a follow-up email.
It captures a phone number for urgent follow-up.
It pins the request to a specific date.
It allows multiple selections without free text.
It captures a numeric value you can filter and sort on.
Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

1Press “Use this template” — a fresh copy of Eye Exam Intake Form lands in your workspace, ready to edit.
2Rename or delete any question, and change what is required. Nothing here is fixed.
3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 3 conditional rules ship with it.

Features conditional validation: if “Do you wear contact lenses?” is Yes, “How many hours a day do you wear them?” becomes mandatory before the form can be sent.
Features advanced show logic: if “Do you drive?” is Yes, the form dynamically exposes “Any difficulty driving at night?”. Otherwise that question never appears.
Features conditional validation: if “Any known eye conditions in the family?” is Yes, “Which condition, and who?” becomes mandatory before the form can be sent.
All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

Sight tests run to a tight clock, so the history is worth collecting beforehand. This intake asks what the patient has noticed — blur at distance or near, headaches when reading, glare when driving at night, double vision, floaters — and when they noticed it, rather than asking them to summarise their vision in one sentence. It records what they currently wear, how old the prescription is, and whether they use contact lenses and for how many hours a day, because wear time drives much of the advice that follows. Occupational questions cover screen hours, driving and any safety requirement at work, which is what determines whether a second pair or a specific coating gets discussed. A short eye-history section covers previous surgery, injury, known conditions and family history of eye disease. General health and medication are included because both are relevant to the eye. Everything is phrased for a patient to answer honestly without knowing optical vocabulary, and interpretation stays with the optometrist during the examination.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Your vision

Full namerequired
Date of birthrequired
Contact numberrequired
What have you noticed?required
When did you notice it?
Date of your last eye test
What do you wear now?required
Do you wear contact lenses?required
How many hours a day do you wear them?

Page 2 — History and daily life

Hours a day on screensrequired
Do you drive?required
Any difficulty driving at night?
Previous eye surgery, injury or known conditions
Any known eye conditions in the family?required
Which condition, and who?
General health conditions and current medication
Any safety eyewear needed for work

17 questions in total.

Example of a completed eye exam intake form

A sample intake showing how a patient describes recent vision changes before a sight test.

Full name: Adaeze Nwosu
Date of birth: 01/06/1992
What have you noticed?: Blur at distance, Headaches when reading
When did you notice it?: Over the last two months
Date of your last eye test: 10/03/2024
What do you wear now?: Glasses
Do you wear contact lenses?: No
Hours a day on screens: 7
Any known eye conditions in the family?: Not sure

Sample data — no real people, addresses or records are shown.

How the form changes as it's filled in

This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “Do you wear contact lenses?”

Makes answers required
If “Do you wear contact lenses?” is Yes, “How many hours a day do you wear them?” becomes required before the form can be submitted.

Driven by “Do you drive?”

Reveals questions
If “Do you drive?” is Yes, the form reveals “Any difficulty driving at night?”.

Driven by “Any known eye conditions in the family?”

Makes answers required
If “Any known eye conditions in the family?” is Yes, “Which condition, and who?” becomes required before the form can be submitted.

Set it up step by step

1
Offer the checklist, then the date
Patients recognise symptoms in a list far better than they describe them, and the date they noticed gives the optometrist the timeline.
2
Ask for screen hours as a number
A number can be compared across visits and drives the practical advice; "a lot" cannot.
3
Send it with the appointment reminder
Two minutes of history collected the night before is two minutes of examination time recovered.
4
Flag family history for the record
Route submissions mentioning family eye disease so the recall interval is set deliberately rather than by default.

Mistakes to avoid

Asking only when the last test was, and never what the patient has actually noticed since.
Skipping contact lens wear time, which is central to most of the advice that follows.
Ignoring general medication, some of which is directly relevant to the eye.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

Read the intake before the test, set the recall interval with the family history in view, and record what was discussed about screens, driving and lens wear.

Works in both layouts

Browse classic templates Browse card templates

Forms that overlap this one

These pages cover the same subject ground as the eye exam intake form, matched on the words people actually search for.

Privacy & compliance

This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.

Frequently asked questions

Does this replace the clinical record of the test?

No. It is the history that arrives before the test; the examination findings and prescription live in your clinical system as they always have.

Is it suitable for children's appointments?

A parent can complete it, though school and reading questions are usually worth adding. For a broader child intake, start from the Pediatric Intake Form.

Why ask about general health?

Several general conditions and medicines have ocular relevance, so the optometrist should see them before the examination rather than after.

Can it double as a contact lens check form?

It captures wear time and comfort well enough to start one, but a full lens aftercare check needs its own fields for lens type, solution and fit.

Is the Eye Exam Intake Form template free to use?

Yes. You can preview and test Eye Exam Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Eye Exam Intake Form template ask for?

It asks 17 questions across 2 pages, 9 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Eye Exam Intake Form form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this healthcare & clinical form work?

3 conditional rules ship with the template: Features conditional validation: if “Do you wear contact lenses?” is Yes, “How many hours a day do you wear them?” becomes mandatory before the form can be sent. Features advanced show logic: if “Do you drive?” is Yes, the form dynamically exposes “Any difficulty driving at night?”. Otherwise that question never appears. Features conditional validation: if “Any known eye conditions in the family?” is Yes, “Which condition, and who?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.

Where do responses to the Eye Exam Intake Form form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Eye Exam Intake Form form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

More forms teams pair with the eye exam intake form.

Related categories

All Healthcare & Clinical templates

Eye Exam Intake Form

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