Watters Vision Care Patient Information Form

Demographics

Please Fill Out The Following:

TitleFirstLastMISuffixNickname
Address:
City: State/Zip Code
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Eye Doctor Misc./Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityState Zip Code
Home Phone:
Work Phone:

Medical History

Please Fill Out The Following Information.  Thank You.

 
Weight   Height ft.  in Race  Ethnicity 
 
Preferred Language  Smoking Status  Alcohol Use 
 
Are You Pregnant Or Nursing?  Due Date / DOB 
 

How Did You Find Out About Our Office?   Details / Other 


Marital status Employer / School Occupation Grade In School
 
What Are Your Hobbies?
 
Please List All Prescription Medications That You Are Taking 
 
Please List All Over-the-Counter Medications That You Are Taking 
 
Please List All Medications That You Are Allergic To. If None, Please Write None 
 
Please List The Name, Address, and Phone Number Of Your Primary Physician
 
Please List Any Eye Conditions You Have, Or Have Had. (i.e. Lazy Eye, Retna Detachment, Cataract, Glaucoma, Or Other)

Please Check Any Conditions Below That Anyone In
Your Family Has, Or Has Had
 
  Relationship To You (i.e. Uncle)
Glaucoma Have You Had Eye Surgery?  If So, What Type 
Macular Degeneration Have You Had An Eye Injury?  If Yes, Please Describe 
Retina Detachment Do You Have Problems With Glare / Light Sensitivity? 
Diabetes Do You Currently Wear Contact Lenses? 
High Blood Pressure Have You Ever Worn Contact Lenses?   If So, What Type?
Autoimmune Disease Are You Interested In Contact Lenses? 
 
NOTES

Please Check Mark Whether Or Not You Have Or Have Had The Following:
 
No Yes No Yes No Yes No Yes No Yes
Glaucoma Spots / Floaters Flashes Double Vision Stinging / Burning / Itching
Weight Loss Weight Gain Fatigue    
Skin Rash Growths Acne Rosacea  
Headaches Migraines Seizures MS  
Dysthyroid Diabetes      
Allergies Sinus Problems Dry Mouth / Throat Cough  
Asthma Bronchitis Emphysema COPD  
Hypertension High Cholesterol Heart Surgery Vascular Disease Heart Disease
Ulcer Reflux      
Kidney Stones Frequent Urination Enlarged Prostate Kidney Disease  
Arthritis Joint Pain Head or Neck Injury    
Anemia Bleeding Problems      
Seasonal Allergies Allergy Shots      
Depression Anxiety Insomnia    
 
Please List Any Types Of Cancer You Have Or Have Had
 
Please List Any Medical Conditions You Have That Are Not Listed Above

If You Have Diabetes, How Many Years Since Your Diagnosis? Last Blood Sugar Date
 
Last A1C   Date

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