Crystal PM Patient Forms

Demographics

Title	*First	*Last	MI	Suffix	Nickname

*Address:
*City:		*State/ZipCode

*Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
*SSN		*Email
*Birthday		Occupation
*Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer/School Name
Primary Doctor		Misc/Guardian

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Ocular History

Reason for your visit?

Please list your current medications
Please list any allergies to medication
Primary Care Physician Physician's Address

Have you or your family ever had any of the following: Do you experience any of the below symptoms:

Yes/No

Relation to Patient

*Amblyopia/Lazy eye

*Blindness

*Cataract

*Color Blindness

*Glaucoma

*Macular Degeneration

*Retinal Detachment

*Strabismus (eye turn)

Other

		Yes/No
	*Blurred Vision
	*Headaches
	*Eyestrain/Fatigue
	*Double Vision
	*Glare
	*Flashes of Light
	*Floaters
	*Dry Eyes
	*Itchy Eyes
	*Watery Eyes
	*Redness

CURRENT EYE WEAR
Glasses - Type
Contact Lenses - Type

Notes

Review of Systems

Do you currently have any of these problems?	Yes or No	If Yes, please describe
*GENERAL: Fever, weight loss, weight gain, fatigue?
*EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
*CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
*RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
*GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
*MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
*SKIN: growths, rashes, acne
*NEUROLOGICAL: Headaches, migraines, seizures
*PSYCHIATRIC: Depression, Anxiety, Insomnia
*ENDOCRINE: Thyroid, Diabetes
*BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
*ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
*GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
*SPECIAL NEEDS: Autistic, Non-Verbal, Tactile Sensitivity, Hearing Impaired, Limited Mobility

Currently pregnant or nursing?
List any previous surgeriess you have had

Family/Social History

SOCIAL HISTORY
Current Occupation Years Employer
Do you drink alcohol? Yes No    How much per day/week?
Do you smoke? Yes No    How much per day/week?
Do you use illegal drugs? Yes No

Race:   Ethnicity:

Smoking Status:

LIFESTYLE
Do you drive? Yes No    Visual difficulty with driving? Yes No
Computer Used? Yes No    Hours per day?
Sports/Hobbies
Do you wear sunglasses? Yes No
Are you interested in thinner/lighter lenses? Yes No
Do you have more than 1 pair of Rx eyewear? Yes No
Are you interested in wearing contact lenses? Yes No
Do you want information on laser vision correction? Yes No
Do you have any family members in need of eyecare? Yes No

                      HAS ANYONE IN YOUR FAMILY
                 EVER HAD ANY OFTHE FOLLOWING

	YES or NO	RELATION TO PATIENT
*Arthritis
*Cancer
*Diabetes
*Heart Disease
*High Blood Pressure
*Kidney Disease
*Autoimmune Disease
*Stroke
*Thyroid Disease
Other

Office Forms

HIPAA Privacy Policies
*I have read and understand the HIPAA Privacy Policies for Pickerington Eyecare
Patient Responsibility Disclosure Statement
*I have read and understand the Patient Responsibility Disclosure Statement for Pickerington Eyecare

Submit Data

How did you first hear about Pickerington Eyecare?

Please Describe (name of friend/family/newspaper/website):

Please review all data before clicking the button:

	Yes/No	Relation to Patient
*Amblyopia/Lazy eye
*Blindness
*Cataract
*Color Blindness
*Glaucoma
*Macular Degeneration
*Retinal Detachment
*Strabismus (eye turn)
Other