Patient Forms

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

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

Is the Billing Address Different?

Vision

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:
Employer/School:

Medical

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:
Employer/School:

Medical History

Referred By:   Referring Doctor:   Preferred Language:

Occupation:   Computer Use:   Gender:

Race:   Ethnicity:

Hobbies:

Height Feet:   Inches:   Weight:

PATIENT AND MEDICAL HISTORY:

Last Eye Exam:   Last Eye Doctor:

OCULAR HISTORY
                                              SELF   RELATIVE  SELF

Cataracts	Dryness or pain in eyes
Glaucoma	Blurred Vision
Macular Degeneration	Double Vision
Retinal Disease	Eye Infection
Eye Disease	Eye Injury
Eye Surgery	Floaters New/worse?
	Flashes New/worse?

Other ocular conditions/Notes:

Eye Meds:

Last Medical Exam: Primary Care Physician: PCP Phone Number:

MEDICAL HISTORY
SELF RELATIVE SELF RELATIVE SELF

Diabetes		Asthma Head Injury
High Blood Pressure		Thyroid Nursing
Elevated Cholesterol		Cancer Pregnant
Lung Disease		Migraines
Heart Disease		Headaches

Any other medical conditions/Notes:

Systemic Meds:

Allergies (Medications and Seasonal):

PERSONAL AND SOCIAL HISTORY:

Smoking Status Amount:   Alcohol Status:   Amount:

Primary Vision Correction:
  Age of current glasses:   Sunspecs?   Interested in Corrective Eye Surgery?

H/o Contact Lenses Wear?   Interested In Contact Lenses?   If no, why not?

Brand of CLs worn in the past:   Replacement Frequency:   Solution:

Drops?   EW?   How many nights/week?   Back up specs for Contact Lenses?

NOTES

Review of Systems

REVIEW OF SYSTEMS

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fatigue Weight gain Weight loss Chronic fever None

CARDIOVASCULAR: Heart surgery Irregular Heartbeat Chest Pain None

EAR, NOSE, THROAT: Hearing loss  Sore throat  Sinus   None

RESPIRATORY: Asthma  Shortness of Breath  Bronchitis  Emphysema  COPD  None

GASTROINTESTINAL: Heartburn  Vomiting  Abdominal pain  None

GENITOURINARY: Kidney  Bladder/Urinary  Genital  None

MUSCULOSKELETAL: Arthritis  Muscle Pain  Joint Pain  Head or neck injury  None

SKIN: Growths  Rashes   Acne  Excessive Dryness  None

NEUROLOGICAL: Headaches  Migraines  Seizures  Numbness  None

PSYCHIATRIC: Depression  Anxiety  Insomnia  None

ENDOCRINE: Diabetes   Thyroid  Problems with other glands  None

BLOOD/LYMPH: Anemia   Cholesterol  Bleeding problems   None

ALLERGIC / IMMUNOLOGIC: Lupus  Seasonal Allergies  Rheumatoid  AIDS  Allergy shots  None

NOTES:

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