Instructions

Please provide as much information as you can on both the Demographics and Medical History sections before submitting the form. Please bring your insurance cards, ID, and any current glasses with you to your appointment. Questions? Call us at 240-776-5062


Demographics





Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Email
Birthday (xx/xx/xxxx) Occupation
Sex Male Female
Marital Status Employer/School Name
Misc/Guardian

Medical History





Please list eye medications you currently take:

Please list other medications you currently take:

No current meds
Please list any over-the-counter medications/supplements you currently take:

Please list medication allergies:

No Medical Allergies
Please list any major injuries or surgeries:

Pregnant Or Nursing?


Review of Systems

Do you currently have problems in any of these areas? If yes, please explain:

GENERAL: Chronic fever or fatigue, unexpected weight gain or loss     No
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth No
CARDIOVASCULAR: High BP, Heart disease, Vascular Disease No
RESPIRATORY: Asthma, Emphysema, COPD, Sleep apnea No
GENITAL, KIDNEY, BLADDER: Kidney disease, frequent urination No
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury No
SKIN: Skin cancer, rashes, Rosacea, Psoriasis No
NEUROLOGICAL: Headaches, migraines, seizures, MS, or other No
PSYCHIATRIC: Depression, Anxiety, Insomnia, Panic disorder No
ENDOCRINE: Thyroid, Diabetes, Pituitary No
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems No
IMMUNOLOGIC / ALLERGY: Rheumatoid, Lupus, Allergies, HIV+ No
GASTROINTESTINAL: IBS, Crohn's, frequent cramping No
CANCER: Current or prior No

Social History

Height:ft. in.
Weight: lbs.
Smoking status:
Alcohol:
Recreational Drugs:
Preferred Language:
Race:
Ethnicity:

Patient Ocular History

What is the main reason for your visit today?
Which eye does it affect?: How severe are the symptoms?:
Has it been changing?:
How long have you noticed the symptoms:
When do you notice the symptoms:
What are you doing when you have the symptoms?:
Does anything make it better?:
Anything associated with the symptoms?:
Are you experiencing any other symptoms or being monitor for any eye diseases?:
Such as blurred vision, red eyes, glare/double vision, dryness, itching/allergy, tearing, floater/flashes,
headaches, eye pain, gritty feeling, light sensitivity, twitching, etc. or been diagnosed with macular degeneration,
cataracts, glaucoma, retinal problems, lazy eye, crossed eye/eye turn, iritis/uveitis, or other eye injuries.
When was your last eye exam?
Doctor:
Additional eye history including eye surgery/LASIK:

Other current symptoms:

Family Eye History

Glaucoma:
Cataracts:
Macular Degeneration:
Retinal Detachment:
Lazy / Crossed eye:

Lifestyle Eye History

Primary Vision Correction:
Do you have back up glasses?
Are you planning to get new glasses?
What type of contacts have you worn in the past:
What is your typical wearing time:
What type of cleaner do you use:
How often do you throw away your lenses:
Please tell us about your hobbies and sports activities:

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

All Ready?