Watters Vision Care Patient Information Form


Please Fill Out The Following:

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?

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? 

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



We at Watters Vision Care are constantly striving to provide the best of care for your eyes. We have recently acquired a instrument which we believe will help us in this quest. This technology has been around for awhile, but only recently has the image quality met our standards.

The device provides what is called an Optomap, which is a laser generated image of the back of your eyes. This includes your retina, optic nerves, maculas and blood vessels. This helps our doctors with identifying eye problems including, glaucoma, macular degeneration, retina detachments and eye cancers.

This does not replace the regular eye examination, but adds more information about your eyes. The images can be compared year to year to help detect subtle changes.

This technology is very expensive and unfortunately, most insurances do not cover the procedure. Most offices charge $39.00 or more for an Optomap Image. We are only charging $29.00 for the images because we want every one of our patients to have access to this technology. For families with children under 18, we only charge $25.00 for each child.

We cannot emphasize enough, how beneficial this procedure is for your ongoing eye care.

Please indicate below whether you would like this procedure as part of your complete eye examination.

Yes, please include the Optomap to help Watters Vision Care provide the best care for my eyes

I decline the Optomap

Name (Or name of parent or guardian):

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