PATIENT INFORMATION FORM

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General Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:	State:	Zipcode:

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

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address:

City	State	ZipCode

REQUIRED QUESTIONS Preferred Language:
Race:
Ethnicity:

PATIENT OCULAR HISTORY Reason For Today's Visit:
Last Eye Exam:
Doctor:
History of ocular problems/diseases:
Ocular Injuries or Surgeries:
Prescription Eye Drops:
Non-Prescription Eye Drops:
Are you interested in updating your glasses?:
Are you interested in Contact Lenses?:
CONTACT LENS WEARERS, PLEASE ANSWER THE FOLLOWING QUESTIONS: Wear Schedule:
Disposal: Solutions:

Please check all that apply:

Glaucoma:	What kind?
Cataracts:
Macular Degeneration:	What kind?
Retinal Detachment:
Crossed/Lazy Eye:

FAMILY OCULAR HISTORY (Please Select Family Member if Applicable) No one in my family have any of these conditions:

Condition

Family Member

Glaucoma:

Mother:

Father

Sibling:

None:

Cataracts:

Mother:

Father:

Sibling:

None:

Macular Degeneration:

Mother:

Father:

Sibling:

None:

Retinal Detachment:

Mother:

Father:

Sibling:

None:

Crossed/Lazy Eye:

Mother:

Father:

Sibling:

None:

Additional Family Ocular History:

PATIENT MEDICAL HISTORY Primary Care Physician:
Last Visit:

Please check all that apply to you:

Diabetes:	Type: Year Diagnosed: A1C:
Hypertension:	Current Status:
Thyroid:	Type:
Cardiovascular:	Type:
Cancer:	Type:

Major Injuries, Surgeries, or Hospitalization:

Please list all vitamins and supplements you take:

Please list all medication allergies:

Please list all medications and dosages:

FAMILY MEDICAL HISTORY No one in my family have any of these conditions:

Condition

Family Member

Diabetes:

Mother

Father

Sibling:

None:

Hypertension:

Mother:

Father:

Sibling:

None:

Thyroid:

Mother:

Father:

Sibling:

None:

Cardiovascular:

Mother:

Father:

Sibling:

None:

Cancer:

Mother

Father

Sibling

None:

SOCIAL HISTORY Hobbies/Recreation:
Smoking History
Alcohol Use:
Desktop Computer Use:
Laptop Computer Use:
Who Referred You:

Please list any additional information you would like the doctor to know:

REVIEW OF SYSTEMS

Do you currently have any of these problems?	Yes No
GENERAL: Fever, weight loss, weight gain, fatigue?
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
PLEASE LIST ANY ADDITIONAL INFORMATION

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Thank You So Much! We look forward to seeing your at your upcoming visit!

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