Patient Forms

PLEASE FILL OUT OR UPDATE Demographics and Medical History AND PRESS SUBMIT BUTTON AT BOTTOM OF PAGE


DEMOGRAPHICS

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
**Cell phone number is required**
Cell Phone*: Can we contact you by text?
EmailCan we contact you by e-mail?
Birthday mm/yy/yyyy
Sex Male Female
Marital Status
Parent/Guardian Name (for Minors)
Billing Information Is The Billing Address the Same? Please check here:
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

MEDICAL HISTORY

Primary Care Physician Name:
Date of Last Physical Exam

Are you pregnant or nursing? Yes No If pregnant, how many weeks/months?

Please check all that apply to your health condition (present or past):
Acne/eczema/rashes/skin disease
Migraines/headaches
Seizures
Blurry vision
Severe eye pain
Thyroid disease
Hayfever/allergies
Asthma/breathing difficulty
Emphysema/COPD
Chronic bronchitis
Lung disease
Sinus problems
Sleep apnea
Prostate disease
Kidney/bladder disease
Chronic stomach pain or disease
High blood pressure
Heart disease
Poor circulation
Diabetes
High cholesterol
Stroke
Arthritis
Joint/muscle pain
Anemia
Bleeding/blood disease
Autoimmune disease
Lupus
Depression
Psychiatric disorder
ADHD
Cancer/tumors
Brain disease
Vertigo
Loss of hearing




SYSTEMIC MEDS (including oral birth control, aspirin, OTC meds, vitamins, home remedies) :
Allergies to medications
List any major injury, surgery, and/or hospitalizations (approximate year of occurence):


EYE HISTORY

Check any eye related conditions you currently experience or have had:

Loss of vision
Distorted vision/haloes
Loss of side vision
Double vision
Chronic dry eyes
Chronic mucus discharge
Chronic Redness
Chronic itching
Constant burning
Excessive tearing/watering
Bright light/glare sensitivity
History of styes or chalazions
Flashes of lights or floaters

If you checked any of the above, please explain:

Check any eye related conditions you currently experience or have had:
Lazy Eye: Which eye?
Crossed eye: Which eye?
Drooping eyelid: Which eye?
Glaucoma: Which eye?
High eye pressure: Which eye?
Diabetes in the eyes: Which eye?
Macular degeneration: Which eye?
Cataracts: Which eye?
Retinal disease: Which eye?
Severe eye infections: Which eye?
Dry eyes: Which eye?
Eye injury: Which eye?
Explain:
Eye surgery: Which eye?
Explain:

Do you wear glasses? Yes No. If yes, how old are your lenses?
Do you wear contact lenses? Yes No. Are they comfortable?
When do you throw away your contacts? Disinfection solution:
Do you sleep in your contacts? If you sleep in your contacts, how many days?

EYE MEDICATIONS (includes prescribed and OTC)


FAMILY HISTORY

Adopted/Family history unknown
Please note this includes siblings, parents, grandparents, and children: (living or deceased)
Blindness
Cataracts
Crossed eyes
Glaucoma
Macular degeneration
Retinal detachment/disease
Alzheimers/Dementia
Rheumatoid Arthritis
Cancer
Diabetes
Heart disease
High blood pressure
High cholesterol
Kidney disease
Thyroid
Auto-immune disease (e.g., MS, Chron's, Lupus, Sjogrens, etc.)
Other


SOCIAL HISTORY

Do you drive?No Yes. Do you have any visual difficulty with driving? No Yes. If yes, please explain:
Do you use tobacco products? If yes, type/amount/how long?
Do you drink alcohol? If yes, glass every day or occassionally?
Do you use illegal drugs? If yes, type/amount/how long?
Have you ever been exposed or infected with: Gonorrhea Chlamydia Hepatitis HIV Syphillis Tuberculosis


WORK/SOCIAL ENVIRONMENT

Occupation (REQUIRED):** If no occupation, please put NONE.
Please check applicable items:
Do you work on a computer?
Do you work outside?
Do you play sports?
Do you weld?
Do you need safety glasses?
Do you work in a dry environment?
Do you work in a dusty environment?
Interested In Contact Lenses?
Interested in Laser Vision Correction?

Hobbies:
NOTES for Doctor:

BIRTHDAY, OCCUPATION, AND CELL PHONE NUMBER IS REQUIRED. PLEASE PRESS WHEN FINISHED.