Crystal PM Patient Forms

Demographics

Patient Information
All fields in red marked with asterisks are required to be filled out. Thank you!

Title	* First	* Last	MI	Suffix	Nickname	Pronoun

* Address:
* City:		* State/ZipCode

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

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Medical History

Patient History

Reason for Visit:

Do you wear glasses?	Y	N
If yes, do you wear them for:	Dist	Near	Both
Do you wear contact lenses?	Y	N

Date of Last Eye Exam:

Date of Last Medical Exam:

Height:	Ft
Weight:	Lb

Do you have allergies to medication?

Y

N

Please list:

Do you have seasonal allergies?	Y	N
Are you taking medications?	Y	N
Are you pregnant?	Y	N
Do you see flashes of light in your eyes?	Y	N
Do you see floating objects in your eyes?	Y	N
Do you have temporary blackouts of your vision?	Y	N
Do you have frequent headaches?	Y	N
Do you use tobacco?	Y	N
Do you drink alcohol?	Y	N

Please list medications:	Please list eye medications:

Do you have:

NONE

High Blood Pressure

Diabetes

Lung Disease

Cancer

Rheumatoid Arthritis

Previously

Seizures

Multiple Sclerosis

HIV

Have you ever had?

NONE

Strabismus (eye turn)

Amblyopia (lazy eye)

Keratoconus

Glaucoma

Diabetic Retinopathy

Macular Degeneration

Dry Eyes

Iritis

Retinal Detachment

Retinal Disease

Optic Nerve Disease

Have you ever had eye surgery for:

NONE

Cataract

Retinal Detachment

Muscle Surgery

Trauma

Lasik/PRK

Foreign Body Removal

Other

Has anyone in your family ever had:

NONE

Blindness

Glaucoma

Diabetes

Cataracts

Macular Degeneration

Keratoconous

Avg. Hrs/day spent on computer:

Occupation:

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Demographics

Medical History

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