Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	TX 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:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
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
Primary Doctor	No Doctor Assigned Dr. Hsu, Sophie Dr. Soong, Steven	Misc/Guardian
Primary Care Doctor

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	TX 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:

Medical History

Lifestyle

Occupation:	Student Retired Homemaker Engineer Other	Employer:
Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other	Preferred Language:	EnglishSpanishFrenchPatient Declined to SpecifyAbkhazianAfar AfrikaansAkanAlbanianAmharicArabicAragoneseArmenianAssameseAvaricAvestan AymaraAzerbaijaniBambaraBashkirBasqueBelarusianBengaliBihari languagesBislama Bokm?l, Norwegian), Norwegian Bokm?lBosnianBretonBulgarianBurmeseCatalan; Valencian Central KhmerChamorroChechen Chichewa; Chewa; NyanjaChinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church SlavonicChuvashCornishCorsicanCree CroatianCzechDanishDivehi; Dhivehi; MaldivianDutch; FlemishDzongkhaEsperantoEstonianEweFaroese FijianFinnishFulahGaelic; Scottish GaelicGalicianGandaGeorgianGerman Greek, Modern (1453-)GuaraniGujaratiHaitian; Haitian CreoleHausaHebrewHereroHindiHiri MotuHungarianIcelandic IdoIgboIndonesianInterlingua (International Auxiliary Language Association)Interlingue; OccidentalInuktitutInupiaqIrishItalianJapaneseJavaneseKalaallisut; GreenlandicKannadaKanuriKashmiriKazakhKikuyu; GikuyuKinyarwanda Kirghiz; KyrgyzKomiKongoKoreanKuanyama; KwanyamaKurdishLaoLatinLatvianLimburgan; Limburger; LimburgishLingala LithuanianLuba-KatangaLuxembourgish; LetzeburgeschMacedonianMalagasyMalayMalayMalayalamMalteseManxMaoriMaori Marathi MarshalleseMongolianNauruNavajo; NavahoNdebele, North; North NdebeleNdebele, South; South NdebeleNdongaNepaliNorthern SamiNorwegian Norwegian Nynorsk; Nynorsk, NorwegianOccitan (post 1500)OjibwaOriyaOromoOssetian; OsseticPaliPanjabi; Punjabi PersianPolishPortuguesePushto; PashtoQuechuaRomanian; Moldavian), MoldovanRomanshRundiRussianSamoanSangoSanskritSardinianSerbianShonaSichuan Yi; NuosuSindhiSinhala; SinhaleseSlovakSlovenian SomaliSotho, SouthernSundaneseSwahiliSwatiSwedishTagalog TahitianTajikTamilTatarTeluguThaiTibetanTigrinyaTonga (Tonga Islands)Tsonga TswanaTurkishTurkmenTwiUighur; UyghurUkrainianUrduUzbekVenda VietnameseVolap?kWalloonWelshWestern FrisianWolofXhosaYiddishYorubaZhuang; ChuangZuluOther

Ocular History

Reason for Visit:
Secondary Reasons:

Last Eye Exam:	1 year 2 years 3 years 5 Years 10 Years Never Other
Interested in Contact Lenses?:	No Yes, Previous Wearer Yes, Never Worn Before Other

Eye Conditions

Glaucoma:

No Yes Other

Cataracts:

No Yes Other

ARMD:

No Yes Other

Other

No Yes Other

Please list all eye medications you are currently taking:

Family History

Unknown family history

Glaucoma:	No Siblings Mother Father Aunt Grandparent Uncle Other	Diabetes:	No Siblings Mother Father Aunt Grandparent Uncle Other	ARMD:	No Siblings Mother Father Aunt Grandparent Uncle Yes Other
Other:	No Cataracts Siblings Mother Father Aunt Grandparent Uncle Other

Medical History

Primary Care Physician:

Last Exam

< 1 year 2-3 years 4-5 years 5-10 years Other

Please list all past injuries and surgeries:
Please list all medications you're currently taking:	No current medications
Please list all drug allergies:	No known drug allergies

Review of Systems

Heart Disease:	No Previous Heart Attacks Pacemaker Defibrillator Bradycardia Tachycardia Arythmia Yes Mild Moderate Severe Yes Other
High Blood Pressure:	No Uncontrolled Poorly Controlled Controlled with Diet Controlled with Medication Controlled with Diet and Medication Diet controlled Medication controlled Diet and Medication controlled Yes Other
High Cholesterol:	No Uncontrolled Diet Controlled Medication Controlled Controlled with Diet and Medication Yes Mild Moderate Severe Other
Vascular Disease:	No Yes Mild Moderate Severe Other
Ears, Nose or Throat:	No Dry Mouth Cough Deaf-Partial Deaf-Total Yes Other
Asthma:	No Mild Moderate Severe In Past Yes Other
Emphysema:	No Mild Moderate Severe Yes Other
Allergies, Hay Fever:	No Seasonal Animals Hives Itch Swelling Rash Sneezing Dust Mold Cats mild moderate severe Yes Other
COPD:	No Mild Moderate Severe Yes Other
Colitis, IBD or Reflux:	No Colitis IBD Reflux Mild Moderate Severe Yes Other
Genital, Kidney or Bladder:	No Kidney Disease Bladder Disease Impotence Frequent Urination Painful Urination Other
Skin Problems:	No Acne Psoriasis Eczema Rosacea Growths Rash Warts Itch Swelling Hives Lupus Other
Headaches, Migraines, etc:	No Migraines Infrequent Migraines Often Headaches Constant Numbness Frontal Tempotal Occipital Severe frequent Severe infrequent Mild infrequent Mild frequent Yes Headaches Other
M.S., Seizures or Bells Palsy:	No M.S. Seizures Bells Palsy Other
Depression or Anxiety:	No Depression Depression, Mild Depression Moderate to Severe Anxiety Anxiety, Mild Anxiety, Moderate to Severe Other
Diabetes:	No borderline Type I Type II Insulin Controlled Diet Controlled Controlled with Oral Meds Gestational Other

FBS:

did not take Other

A1C:

4 5 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9 10 11 12 Other

Type:

did not take Other

Years:

4 5 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9 10 11 12 Other

Thyroid or Other Glands:	No Hypothyroid Hyperthyroid Other
Arthritis:	No Osteoarthritis Rheumatoid Arthritis Rheumatoid Arthritis, Mild Rheumatoid Arthritis, Moderate to Severe JRA Yes Yes, nonspecific Mild Moderate Severe Other
Other Muscle or Joint Pain:	No Cramps Joint Pain Stiffness Swelling Yes Other
Cancer:	No Breast, in remission - cured Breast Prostate Lung In remission Cured Other
Anemia:	No Controlled with medications/ Supplements Yes Other
Bleeding Problems:	No Yes Due to Medications Other
Pregnant:	No 1st trimester 2nd trimester 3rd trimester Other
Other:	No Other

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