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13695 Colorado Boulevard Thornton, CO 80602
Office (303) 450-2020
Fax (303) 920-1440

Please Fill out the Form Below and Submit at Bottom of Page

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Who Referred You? How did you hear about us?
Home Phone: Work Phone:
Other Phone: Misc/Guardian
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
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

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:

Medical Insurance

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:

PATIENT HISTORY

VISUAL HISTORY When was your last eye exam? Location of last eye exam?

Do you wear glasses? Full-timePart-time

Glasses Purpose?
Do you have backup glasses?

Do you wear contact lenses? YesNo
Full-timePart-time
SoftRGP

Interested in Contact Lenses?

How many hours per day do you spend on a computer and/or tablet?

Do you have any of the following:
Blurred Vision
Itchy Eyes
Glaucoma
Dry, gritty, burning eyes
Has Punctal Plugs
Had Punctal Plugs in Past
Eye Turn (Strabismus)
Keratoconus
Amblyopia (Lazy Eye)
Retinal Detachment
Macular Degeneration
Cataracts

Family History:
Adopted: Family History Unknown
Lazy Eye (Amblyopia)
Glaucoma
Blindness
High Blood Pressure
Cataracts
Macular Degeneration
Diabetes
Eye turn (Strabismus)

Eye Injuries?
Eye Surgeries?
Interested in Lasik?
Are there any other notes on visual history you would like the Doctor to know about?
MEDICAL HISTORY Primary Physician's Name:

How is Your General Health?

Height? Feet:Inches:? Weight?(lbs)
CURRENT MEDICATIONS No current medications

Current Medications & Drops (RX & OTC):

Taken For (Reason/Disease/Condition):


Current Medications & Drops (RX & OTC):

Taken For (Reason/Disease/Condition):


Current Medications & Drops (RX & OTC):

Taken For (Reason/Disease/Condition):


Are you allergic to any medications?
No known drug allergies

REVIEW OF SYSTEMS
DO YOU CURRENTLY HAVE ANY OF THESE CONDITIONS OR SYMPTOMS?


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: Arthritis, 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, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
SOCIAL HISTORY Hobbies?

Race? Ethnicity? Preferred Language?

Smoking Status? Do you drink alcohol?

Pregnant or nursing?NoYes
Due Date?
EYE COMFORT QUESTIONNAIRE
1. during a typical day in the past month, how often did your eyes feel discomfort?
Score:

2. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?
Score:

3. During a typical day in the past month, how often did your eyes feel dry?
Score:

4. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?
Score:

5. During a typical day in the past month, how often did your eyes look or feel excessively watery?
Score:

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