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Demographics


Patient Information
TitleFirstLastMISuffixNickname
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
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

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:

Adult History

If you are new to our office, please share with us how you found us.
 

Do you...? (Check all that apply)
wear prescription glasses?
wear contact lenses?  If so, what kind?

                                             Solution used:   
experience discomfort with your contacts?
use over-the-counter eye drops?
use reading glasses?
work at a computer? If so, approximately how many hours a day?

Are you interested in contact lenses? (Additional fees apply)

What are your hobbies?

What specific problems do you have with your vision, eyes, glasses, or contact lenses that you would like to discuss with the doctor today?

Date of Last Eye Exam:
Previous Eye Doctor:     

In the past 6 months, have you experienced any of the following? (Please check all that apply)

Blurry Vision Eye turn
Double Vision Flashes of light
Floaters/seeing spots Eye Injury/Trauma
Eye Fatigue Sensitivity to light
Red eyes Itching/burning eyes
Dry Eye Watery eyes

 

 

 

 

 

Do you have a family history of any of the following? (Please check all that apply)

Blindness Eye Disease
Glaucoma Stroke
Macular Degeneration Heart Disease
Diabetes Strabismus/Eye Turn
Thyroid Condition Autoimmune Disease

 

 

 

  

 

Primary Physician:

Pharmacy 

CURRENT MEDICATIONS (Please list ALL medications including eye drops and supplements)

Please list any ALLERGIES to medications.

Please list any surgeries, including eye surgeries.

REVIEW OF SYSTEMS: Please check the box beside any condition you currently have, or have had in the following areas:

CONSTITUTIONAL EAR,NOSE,THROAT&MOUTH
Fatigue Hearing Loss
Weight gain Sinus Infection/Problems
Weight Loss Dry Mouth/Throat
CARDIOVASCULAR RESPIRATORY
High Blood Pressure Asthma
High Cholesterol COPD
Heart Disease/Heart Attack Emphysema
Congestive Heart Failure Chronic Cough
GASTROINTESTINAL GENITOURINARY
IBS Bladder or Kidney Problems
Acid Reflux Ovarian/Uterine Cancer
Ulcers Prostate Cancer
SKIN MUSCULOSKELETAL
Cancer Arthritis
Eczema Joint Pain
Rashes Muscle Pain
NEUROLOGICAL ENDOCRINE
Headaches/Migraines Type 1 Diabetes
Seizures Type 2 Diabetes
Stroke Hyperthyroid
Alzheimer's Hypothyroid
PSYCHIATRIC HEMATOLOGIC/LYMPHATIC
Depression Anemia
Anxiety Breast Cancer
Mood disorder Bleeding/Clotting Problems
ALLERGIC/IMMUNOLOGIC  
Seasonal Allergies  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you checked any of the boxes above or have a condition not listed, please explain further:

Are you pregnant or nursing? If pregnant, how many weeks?

Are you a smoker? Do you drink alcohol? If yes, how often/much:

Do you use other substances? If yes, what type/how often/amount:

OPTIONAL Demographic Information: (This information if obtained for reporting purposes only)
Race: Ethnicity:

Child History

If you are new to our office, please share with us how you found us.

Parent(s) Name(s):
Parent SSN:
Parent(s) Occupation(s):

Child's Grade Level: School:

Does your child...? (Check all that apply)
wear prescription glasses?

wear contact lenses? If so, what kind? Solution used:

have a rapidly increasing prescription

participate in sports?

Are you considering contact lenses for your child?

What specific concerns regarding your child's vision would you like to discuss with the doctor today?

How long has this problem/difficulty been observed?

Date of Last Eye Exam: Previous Eye Doctor:

In the past 6 months, has your child experienced any of the following? (Please check all that apply)

Blurry Vision Eye Fatigue Eye turn
Double Vision Itching/burning eyes Eye Injury/Trauma
Headaches Difficulty Reading Red eyes
Sensitivity to light Amblyopia/"Lazy Eye" Dry Eye
Color Blindness Reversals  

 

 

 

 

 

Other eye problems/issues:

Do you have a family history of any of the following? (Please check all that apply)

Blindness Heart Disease
Glaucoma Brain Tumor
Macular Degeneration Strabismus/Eye Turn
Diabetes Learning Disability
Thyroid Condition Epilepsy/Seizures
Eye Disease Autoimmune Disease

 





 

 

Primary Physician:

CURRENT MEDICATIONS (Please list ALL medications including eye drops and supplements)

Please list any ALLERGIES to medications (including topical medications):

Premature birth? Any complications during pregnancy? If yes, please describe:

Shown normal development? Had physical/developmental therapy?

Please list serious illnesses, bad falls, etc.:

Please list any surgeries, including eye surgeries.

Has your child ever been diagnosed or treated for any of the following health conditions? (Please check all that apply)

Type 1 Diabetes Seizures Depression
Type 2 Diabetes Stroke Anxiety
 
Hyperthyroid Asthma Mood disorder
Hypothyroid Headaches/Migraines Autoimmune Disorder
Skin lesions/rashes/eczema Seasonal allergies Cancer

 

 






If your child has any other health conditions not listed above, please include those here:


Does your child use an Ipad/tablet in the classroom?

How much screen time does your child get per day?
Does your child have a 504 plan or I.E.P. at school?

Has your child had extra help or tutoring in school?

Has a grade been repeated?
If so, which?

How would you describe your child's reading ability?
Does he/she like to read for fun?
School/after-school activities your child is involved in:
Do you feel your child is achieving up to potential?

OPTIONAL Demographic Information: (This information if obtained for reporting purposes only)
Race: Ethnicity:

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