Allure Eyecare Clinic Patient Form



Please Provide Driver's License, Vision, and Medical Insurance Cards to the Receptionist.

 


Patient Information
First Last MI
Address
City State/ZipCode
Guardian (if patient is a minor)
Home Phone
Cell Phone
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Student
Marital Status Employer / School Name
Billing Information Is The Billing Address the Same?
First Last Direct Phone:
Address City State ZipCode
Phone:



WHAT IS THE REASON FOR YOUR VISIT?



EYE HEALTH ASSESSMENT FOR DISEASES - PLEASE CHOOSE ONE:



TELL US ABOUT YOUR EYE HISTORY

Do You Use Any Eye Medications? When Was Your Last Eye Exam?
Any Past Eye Surgeries/Injuries? What Do You Use for Your Primary Vision Correction?
If You Wear Contact Lenses, What Brand Are You Currently In? Replacement Schedule of Lenses

REVIEW OF SYSTEMS

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Gastrointestinal:
Psychiatric: Musculoskeletal:
Blood/Lymph: Immune:
Neurological: Genitourinary:
Endocrine: Pregnant/Nursing  



CURRENT MEDICATIONS

Medications Over The Counter (OTC)
Vitamins Allergies

SOCIAL HISTORY

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Some STD's Have Ocular Manifestations. Do You Have Any of These?


FAMILY MEDICAL HISTORY

Unknown family history
Glaucoma Cataracts
Macular Degeneration Retinal Detachment



HOW DID YOU FIND US?