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Demographics

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone: (numbers only)
Work Phone: (numbers only)
Other Phone: (numbers only)
Cell Phone: (numbers only)
Preferred Contact Method:
Email
Birthday
Sex	Male Female
Marital Status
Primary Doctor

Billing Information Is The Billing Address Different?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Patient Information

Do you wear glasses:	Full-time Part-time
If part-time, how often/when?
I wear my contacts:	Full-time Part-time

	If part-time, how often/when?
	Soft Rigid Gas Permeable
	Current Brand:
	Are your lenses comfortable?	Yes No
	How old is your current pair?
	What is your replacement schedule?
	What solution do you use?

Please list all eyedrops you use (OTC and Rx):
How often used?
Other eye disease or condition
Describe any visual symptoms from computer use:
How many hours a day do you use a computer?
List any eye surgeries:
Describe any eye injuries:

Physician's Name: Fax # Last Visit Date:

Preferred Pharmacy: Fax#

REVIEW OF SYSTEMS:

Constitutional (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ears, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, sollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing, asthma)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux(GERD), jaundice, nausea, vomiting)

Genital, Kidneys, Bladder (e.g., bladder/urinary problems. pain, discharge, menstrual changes)

Muscles, Bones, Joints(e.g., pain, stiffness, swelling, weakness, limited movement)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g.,depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergic/Immunologic (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

List all medications you are currently taking (including any OTC/vitamins):

No Meds

Drug Allergies:

No Drug Allergies

Pregnant/ nursing? Yes No Due/birth date?

Notes:

Personal and Family History

Family history is unknown/adopted

	Self	Mother	Father	Sibling	Describe
Eye turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
High Cholesterol
Other Inherited Disease

Height ft. in., Weight: lbs.

Eye Color

For Diabetics

Date of Diagnosis: Time in Range (TIR): A1C:

Endocrinologist: Fax#:

SOCIAL HISTORY