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Demographics

Title*First*LastMISuffixNickname
*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?
TitleFirstLastMISuffix
Address

CityStateZipCode
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





 


















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




 













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Patient Responsibility Disclosure Statement
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How did you first hear about Pickerington Eyecare?
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