Patient Information

Patient Information

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Miss Dr. Fr.

Address: City: State/ZipCode AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone: Work Phone: Other Phone: Cell Phone: Preferred Contact Method: Home Phone Work Phone Cell Phone Other Phone Text Message Email Last 4 of SSN Email Birthday Occupation Sex Male Female Employment Status Employed Full-Time Student Part-Time Student Marital Status Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Employer/School Name Guardian

Medical History

When was your last eye exam?	When was your last health exam?
Less Than Six Months Ago One Year Ago Two Years Ago Three Years Ago Four Years Ago Five Years Ago More Than Five Years Ago Never	Less Than Six Months Ago One Year Ago Two Years Ago Three Years Ago Four Years Ago Five Years Ago More Than Five Years Ago Never

Have you ever been diagnosed with:	Has anyone in your family ever been diagnosed with:
Diabetes   No Yes Type II Type I Borderline Other	Diabetes   No Yes Mother Father Sibling(s) Grandparent(s) Other
Heart Disease   No Yes Coronary Artery Disease Arrythmia Endocarditis Other	Heart Disease   No Yes Mother Father Sibling(s) Grandparent(s) Other
Ear, Nose, Throat Disorders   No Yes Enironmental Allergies Sinusitis Rhinitis Tinnitus Other	Ear, Nose, Throat Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Respiratory Disorders   No Yes Bronchitis Asthma COPD Lung Cancer Pneumonia TB Sleep Apnea Wheezing Shortness of breath Other	Respiratory Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
GI, Kidney Disorders   No Yes Crohn's Disease Uclerative Colitis Infection Diarrhea Constipation Celiac Disease Inflammatory Bowl Disease Other	GI, Kidney Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Muscle, Bone, Joint Disorders   No Yes Arithritis Rheumatoid Arithritis Myasthenia gravis Marfan's Syndrome Pain Other	Muscle, Bone, Joint Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Skin Disorders   No Yes Psoriasis Eczema Rosacea Acne Rash Other	Skin Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Neurological Disorders   No Yes Headaches Seizures Epilepsy Numbness Pain MS Parkinson's Disease Other	Neurological Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Thyroid Disorders   No Yes Hyperthyroidism Hypothyroidism Grave's Disease Hashimoto's Disease Other	Thyroid Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Immunologic, Blood, Lymph Disorders   No Yes Hypercholesterolemia Anemia Sickle Cell Anemia Vitiligo Lupus HIV / AIDs Hepatitis Sclerodema Sjogrens Alopecia Other	Immunologic, Blood, Lymph Disorders   No Yes Mother Father Sibling(s) Grandparent(s) Other
Hypertension   No Yes Borderline Controlled Other	Hypertension   No Yes Mother Father Sibling(s) Grandparent(s) Other

Do you have any of the following eye conditions:	Does anyone in your family have any of the following eye conditions:
Amblyopia (Lazy Eye)   No Yes	Amblyopia (Lazy Eye)   No Yes Mother Father Sibling(s) Grandparent(s) Other
Blindness,Vision Loss   No Yes Right Eye Left Eye Other	Blindness,Vision Loss   No Yes Mother Father Grandparent(s) Other
Cataracts   No Yes Right Eye Left Eye Had cataract surgery right eye had cataract surgery left eye had cataract surgery both eyes Other	Cataracts   No Yes Mother Father Sibling(s) Grandparent(s) Other
Color Deficient   No Yes	Color Deficient   No Yes Mother Father Sibling(s) Grandparent(s) Other
Glaucoma   No Yes	Glaucoma   No Yes Mother Father Sibling(s) Grandparent(s) Other
Macular Degeneration   No Yes	Macular Degeneration   No Yes Mother Father Sibling(s) Grandparent(s) Other
Retinal Issues   No Yes Retinal Detachment Macular Hole Other	Retinal Issues   No Yes Mother Father Sibling(s) Grandparent(s) Other
Strabismus(Crossed Eyes)  No Yes	Strabismus(Crossed Eyes)  No Yes Mother Father Sibling(s) Grandparent(s) Other
Eye Diseases   No Yes Fuch's Endothelial Dystrophy Keratoconus Floaters - Vitereal Degeneration Flashes Other	Eye Diseases   No Yes Mother Father Sibling(s) Grandparent(s) Other
Other

Are you experiencing any of the following eye symptoms?

Foreign Body Sensation, Irritation   No Yes Right Eye Left Eye Both Eyes

Glare   No Yes Right Eye Left Eye Both Eyes

Dry Eyes   No Yes Right Eye Left Eye Both Eyes

Eye Pain   No Yes Right Eye Left Eye Both Eyes

Itching   No Yes Right Eye Left Eye Both Eyes

Double Vision No Yes

Floaters, Spots, Flashing   No Yes Right Eye Left Eye Both EyesFalshes and Floaters Other

Blurred Distance Vision   No Yes Right Eye Left Eye Both EyesOther

Blurred Near Vision   No Yes Right Eye Left Eye Both EyesOther

Discharge   No Yes Right Eye Left Eye Both EyesMucus Watery Ropey Other

Redness   No Yes Right Eye Left Eye Both EyesOther

Headaches   No Yes

Other

Medications	Eye Medications	Allergies to Medications	Environmental Allergies

Past Surgeries or Illnesses	Primary Care Physician (name, clinic, phone number)

Social History

Do you currently wear glasses?

No Yes

If so, how old are they?

<1 year 1 year 2 years 3 years 4-5 years >5 years Other

How many hours a day do you use a computer?

How far away is your computer screen?

Do you wear sunglasses?

No Yes

If so, are you sunglasses your prescription?

No Yes

Do you currently wear contacts?

No Yes

If no, are you interested in contacts?

No Yes

How many hours a day do you wear your contacts?

What kind of contact lens solution do you use?

How often do you replace your contacts?

Do you use nutritional supplements?

No Yes

Do you engage in regular exercise?

No Yes Other

Do you drink alcohol?

No Yes

Do you use tobacco products?

No Yes

Do you use illegal drugs?

No Yes

Are you pregnant or nursing?

No Yes

What is your preferred language?

What is your ethnicity?

White African American Hispanic Other

What are your hobbies and interests?

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