Eye exam form: collect eye history before the appointment

Reading a chart is easy. Remembering your family's eye history under a bright light is not. I would rather send patients one link before the appointment, so they answer at home with their glasses on the table.

About the visit

The reason for the exam sets the plan for the hour. A routine check, new glasses and an irritated eye are different appointments. Name, birth date and phone let you match the person to the slot.

About their eyes today

What they wear, which lens brand, when they last had an exam and what they have noticed lately. Screen hours matter more every year. This part is the patient's own view, and it is often the first clue.

About their background

Family eye conditions, health conditions that affect the eyes, drops and past surgery. These are the answers people forget in the chair.

Who fills it and who reads it

Patients fill it in, or hand it to their own AI. The optometrist or the front desk reads the rows. See forms for clinics.

A patient's AI would ask "Why are you booking an exam?" Then "Do you wear glasses or contacts?" Then "Has anyone in your family had glaucoma?" It shows all answers and sends only after a yes. See agent-fillable forms.

One tip

Add a line to the booking message: bring your current glasses. Check your local privacy rules before collecting health data. This is a form, not medical advice. A patient intake form covers general details, and a massage intake form shows a similar layout for another practice.

Questions

Can I use this for children?

Yes, with a parent or guardian answering. Add a guardian name to your copy of the form, and keep the questions about symptoms and family history, which a parent can usually answer.

How do I spot patients who need extra time?

Download the CSV and filter exam_reason for eye pain or blurry vision, then check eye_symptoms. Those rows tell you who to look at first. Urgent problems still belong on the phone.

What if the patient does not know their contact lens brand?

The lens brand and last exam date are optional. The patient can leave them empty, or their AI can ask them to check the box or the packet first.

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text

Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Getting ready for your eye exam",
  "description": "Please answer before your appointment. It gives the optometrist a head start so more of your time goes to the exam.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "contact_phone",
      "label": "Phone",
      "type": "phone"
    },
    {
      "id": "exam_reason",
      "label": "Why are you booking an exam?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Routine eye exam",
        "New glasses or contact lenses",
        "Eye pain or irritation",
        "Blurry or double vision",
        "Follow-up visit",
        "Another reason"
      ]
    },
    {
      "id": "vision_aids",
      "label": "What do you wear now?",
      "type": "multi_choice",
      "options": [
        "Glasses",
        "Contact lenses",
        "Reading glasses",
        "Nothing"
      ]
    },
    {
      "id": "lens_brand",
      "label": "Contact lens brand, if you know it",
      "type": "short_text",
      "max_length": 200
    },
    {
      "id": "last_exam_date",
      "label": "Date of your last eye exam, as best you remember",
      "type": "date"
    },
    {
      "id": "eye_symptoms",
      "label": "Have you noticed any of these?",
      "type": "multi_choice",
      "options": [
        "Headaches",
        "Eye strain",
        "Dry or itchy eyes",
        "Floaters or flashes",
        "Trouble driving at night",
        "Sensitivity to light"
      ]
    },
    {
      "id": "screen_hours",
      "label": "Hours a day you look at a screen",
      "type": "number",
      "min": 0,
      "max": 24
    },
    {
      "id": "family_eye_history",
      "label": "Eye conditions in your close family",
      "type": "multi_choice",
      "options": [
        "Glaucoma",
        "Macular degeneration",
        "Cataracts",
        "Retinal detachment",
        "None that I know of"
      ]
    },
    {
      "id": "health_conditions",
      "label": "Health conditions that can affect the eyes",
      "type": "multi_choice",
      "options": [
        "Diabetes",
        "High blood pressure",
        "Thyroid condition",
        "An autoimmune condition",
        "None of these"
      ]
    },
    {
      "id": "eye_drops_medicines",
      "label": "Eye drops or medicines you use",
      "type": "long_text",
      "max_length": 800
    },
    {
      "id": "past_eye_surgery",
      "label": "I have had eye surgery or laser treatment",
      "type": "checkbox"
    }
  ]
}

Or call the API

bash

curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Getting ready for your eye exam","description":"Please answer before your appointment. It gives the optometrist a head start so more of your time goes to the exam.","fields":[{"id":"patient_name","label":"Your full name","type":"short_text","required":true,"max_length":150},{"id":"birth_date","label":"Date of birth","type":"date","required":true},{"id":"contact_phone","label":"Phone","type":"phone"},{"id":"exam_reason","label":"Why are you booking an exam?","type":"single_choice","required":true,"options":["Routine eye exam","New glasses or contact lenses","Eye pain or irritation","Blurry or double vision","Follow-up visit","Another reason"]},{"id":"vision_aids","label":"What do you wear now?","type":"multi_choice","options":["Glasses","Contact lenses","Reading glasses","Nothing"]},{"id":"lens_brand","label":"Contact lens brand, if you know it","type":"short_text","max_length":200},{"id":"last_exam_date","label":"Date of your last eye exam, as best you remember","type":"date"},{"id":"eye_symptoms","label":"Have you noticed any of these?","type":"multi_choice","options":["Headaches","Eye strain","Dry or itchy eyes","Floaters or flashes","Trouble driving at night","Sensitivity to light"]},{"id":"screen_hours","label":"Hours a day you look at a screen","type":"number","min":0,"max":24},{"id":"family_eye_history","label":"Eye conditions in your close family","type":"multi_choice","options":["Glaucoma","Macular degeneration","Cataracts","Retinal detachment","None that I know of"]},{"id":"health_conditions","label":"Health conditions that can affect the eyes","type":"multi_choice","options":["Diabetes","High blood pressure","Thyroid condition","An autoimmune condition","None of these"]},{"id":"eye_drops_medicines","label":"Eye drops or medicines you use","type":"long_text","max_length":800},{"id":"past_eye_surgery","label":"I have had eye surgery or laser treatment","type":"checkbox"}]}'

JSON definition

json

{
  "title": "Getting ready for your eye exam",
  "description": "Please answer before your appointment. It gives the optometrist a head start so more of your time goes to the exam.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "contact_phone",
      "label": "Phone",
      "type": "phone"
    },
    {
      "id": "exam_reason",
      "label": "Why are you booking an exam?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Routine eye exam",
        "New glasses or contact lenses",
        "Eye pain or irritation",
        "Blurry or double vision",
        "Follow-up visit",
        "Another reason"
      ]
    },
    {
      "id": "vision_aids",
      "label": "What do you wear now?",
      "type": "multi_choice",
      "options": [
        "Glasses",
        "Contact lenses",
        "Reading glasses",
        "Nothing"
      ]
    },
    {
      "id": "lens_brand",
      "label": "Contact lens brand, if you know it",
      "type": "short_text",
      "max_length": 200
    },
    {
      "id": "last_exam_date",
      "label": "Date of your last eye exam, as best you remember",
      "type": "date"
    },
    {
      "id": "eye_symptoms",
      "label": "Have you noticed any of these?",
      "type": "multi_choice",
      "options": [
        "Headaches",
        "Eye strain",
        "Dry or itchy eyes",
        "Floaters or flashes",
        "Trouble driving at night",
        "Sensitivity to light"
      ]
    },
    {
      "id": "screen_hours",
      "label": "Hours a day you look at a screen",
      "type": "number",
      "min": 0,
      "max": 24
    },
    {
      "id": "family_eye_history",
      "label": "Eye conditions in your close family",
      "type": "multi_choice",
      "options": [
        "Glaucoma",
        "Macular degeneration",
        "Cataracts",
        "Retinal detachment",
        "None that I know of"
      ]
    },
    {
      "id": "health_conditions",
      "label": "Health conditions that can affect the eyes",
      "type": "multi_choice",
      "options": [
        "Diabetes",
        "High blood pressure",
        "Thyroid condition",
        "An autoimmune condition",
        "None of these"
      ]
    },
    {
      "id": "eye_drops_medicines",
      "label": "Eye drops or medicines you use",
      "type": "long_text",
      "max_length": 800
    },
    {
      "id": "past_eye_surgery",
      "label": "I have had eye surgery or laser treatment",
      "type": "checkbox"
    }
  ]
}

An eye exam form that saves chair time