| WELCOME TO OUR OFFICE | ||||||||
| fields marked with an "*" are required | ||||||||
| Name | * | |||||||
| Today's Date | mm/dd/yyyy | |||||||
| Spouse or Parent | * | |||||||
| Mailing Address | * | |||||||
| City | * | |||||||
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| Date of Birth | mm/dd/yyyy * | |||||||
| Age | * | |||||||
| Sex: | Male | |||||||
| Female | ||||||||
| Home Phone | xxx-xxx-xxxx * | |||||||
| Work Phone | xxx-xxx-xxxx * | |||||||
| Social Security # | xxx-xx-xxxx * | |||||||
| Email Address | ||||||||
| (for patient communication only) | ||||||||
How did you first hear about our office?
| Yellow Pages | Newspaper |
| Radio | Community Event |
| Friend/Relative | Who? |
| Physician | Who? |
| MEDICAL HISTORY | ||||
| Allergies | Arthritis | Heart Disease | ||
| Asthma | Cancer | Skin Disorder | ||
| Diabetes | Cataracts | High Blood Pressure | ||
| Eye Injury | Eye Surgery | Glaucoma | ||
| Nerves | Kidney Problems | |||
| Other | ||||
CURRENT MEDICATIONS |
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Medication Name |
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| Antihistamines | ||||
| Blood Pressure Pills | ||||
| Diuretic (water pill) | ||||
| Oral Contraceptives | ||||
| Sleeping Tablets | ||||
| Eye Drops | ||||
| Others | ||||
| Allergies to Medications | ||||
| Date of Last Eye Exam | xx/xx/xxxx | |||
| Name of Last Eye Doctor | ||||
| Date of Last Physical Exam | xx/xx/xxxx | |||
| Name of Physician | ||||
| FAMILY MEDICAL HISTORY | ||||
Relationship to you |
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| Blindness | ||||
| Glaucoma | ||||
| Diabetes | ||||
| High Cholesteral | ||||
| Other | ||||
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| This information is kept strictly confidential. However, you may discuss this portion with the doctor if you prefer. This information is important for medical purposes as well as compliance with insurance directives. | ||
| Would prefer to discuss your Social History information with your doctor? | ||
| YesNo | ||
| Do you use tobacco products? | ||
| YES NO | ||
| Do you drink alcohol? | ||
| YESNO | ||
| Employer (or School) | ||
| Occupation (or Grade) | ||
| What is the major purpose of this visit? | ||
| Any problems with your present contact lenses or glasses? | ||
| Vision Insurance | Medicare | Medicaid |
| VSP | Blue Cross | |
| Flex Plan | ||
| Other |
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How will you settle your account?
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| Check | Financing | Credit Card | Insurance | Cash |
| Do you experience........(check those that apply) | |
| Burning | Uncomfortable Glasses |
| Itchiness | Sudden loss of vision |
| Nausea | Sensitivity to light |
| Watery Eyes | Fainting or dizziness |
| Double Vision | Blurry distance vision |
| Flashes of Light | Blurry near vision |
| Glare or Reflection | Gritty feeling in eyes |
| Soreness | Objects floating in vision |
| Eye Strain | Trouble seeing at night |
| Headaches | Dryness |
| Redness | Other |
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| Do You........(check the box if your answer is yes) | |
| Work on a computer for long periods of time? | |
| Have only one pair of glasses? | |
| Want information on thinner, lighter lenses? | |
| Wear bifocals? | |
| Want information on "no line" bifocals? | |
| Prefer not to wear your glasses at times? | |
| Spend a lot of time outdoors? | |
| Ever find a need for prescription sunglasses? | |
| Have problems with glare or reflections (ex: night driving)? | |
| Do work requiring safety glasses? | |
| Participate in sports? | What? |
| Want more information about corrective vision surgery? | |
| Wear or ever tried wearing contacts? | |
| What kind? | |
When you are finished, please click on the Print button only once. If you would like to clear the form and start over, click on the Reset button.
