Today's Date
   Date of Last Exam
 
Title
   Name
 
Nickname
Address
City
  State
  		 Zip
 
Date of Birth
 Age
 Sex
Home Phone
 Work Phone
Primary Contact Number
Email
Social Security Number
Employer (or School)
Occupation (or Grade)
 
 
 
 
Personal Medical History
Yes / No Yes / No
  Allergies       Arthritis  
  Asthma       Cancer  
  Skin Disorder       Diabetes  
  Eye Disease       Heart Disease  
  Eye Injury       High Blood Pressure  
  Eye Surgery       Kidney  
  Lazy Eye       Nerves  
  Cataracts  
  Other Medical Surgery
  
 
 
 
 


Current Medications (Rx or Over the Counter)

Allergy Meds
   
Diuretics (Water Pills)
   
Blood Pressure Pills
   
Oral Contraceptives
Sleeping Tablets
Eye Drops
Other
Allergic Reactions to Medication
Are you currently under the care of a physician?
Yes   No
Name of Physician
    Family Medical History
(Please list relationship with persons listed below.)
Blindness / Lazy Eye
Cataracts
Glaucoma
Diabetes
Heart Disease
Other
 
 
 
 

 What is the major purpose of this visit?
 

 Any Problems with your current contacts or glasses?
 
 Spouse (or Parent's Name)
 
 Spouse (or Parent's Work #)
 
 Please list any other family members, and their ages?
 (Check those patients in our office)
   
   
 Will you be using any vision insurance for this visit?
 Yes   No
 If so what provider will you be using?
 
 Major Medical Insurance
 
 Person Responsible for payment
 
 Responsible Party's SS#
 
 
 
 
 
 How will you settle your account today?
 Check Cash Visa/MC/Discover
 
 
 
 
 Do You...
 ...Work at a computer for long periods?
 Yes No

 ...Have more than one pair of glasses?
 Yes No

 ...Have perscription sunglasses?
 Yes No

 ...Have hobbies, play sports?
 Yes No
  Etc.

 Have you ever worn contacts?
 Yes No

 Are you currently wearing contacts?
 Yes No

 What Kind?
 

 Solutions used?
 

 Are you interested in contacts?
 Yes No

 Are you interested in Laser Surgery?
 Yes No
 
 
 
 
Do you experience... (Please Check All That Apply)

Blurry Distance Vision
Spots

Blurry Near Vision
Trouble Seeing at Night

Itchiness
Glare or Reflection

Tearing
Flashes of Light

Red Eyes
Sesitivity to Light

Burning
Reading Problems

Dryness
Headaches

Gritty Feeling in Eyes
Eye Strain

Contact Lens Problems
Double Vision
 
 
 
 
 How did you hear about our office?
  Friend Relative
 Name 
 Another Health Care Provider?
 
 Yellow Pages - which directory?
 
 Newspaper article?
 
 Civic or Community event?
 
  Other