Demographics

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

Address:
City:		State/Zip Code	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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Eye Doctor	No Doctor Assigned Dr. Watters, Kevin Dr. Ray, Leah Dr. Thompson, John	Misc./Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	Zip Code
	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

Please Fill Out The Following Information.  Thank You.
Weight   Height 1 2 3 4 5 6 7 ft.  in	Race  (Declined) American Indian or Alaska Native Asian, Black or African American Native Hawaiian or Pacific Islander White		Ethnicity
Preferred Language  English Spanish Russian French German Chinese Unknown None Given	Smoking Status  Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoker Smoker Current Status Unknown Unknown if Ever Smoked		Alcohol Use  None Rare Light Moderate Heavy Decline
Are You Pregnant Or Nursing?  No Yes Unsure	Due Date / DOB
How Did You Find Out About Our Office?  Family Friend None Internet Yellow Pages Insurance Drove By Office The Reflector Other  Details / Other

Marital status	Employer / School Unknown	Occupation	Grade In School Kindergarten Pre-School 1 2 3 4 5 6 7 8 9 10 11 12 College
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?  Yes No	If So, What Type
Macular Degeneration		Have You Had An Eye Injury?  Yes No	If Yes, Please Describe
Retina Detachment		Do You Have Problems With Glare / Light Sensitivity?  Yes No
Diabetes		Do You Currently Wear Contact Lenses?  Yes No
High Blood Pressure		Have You Ever Worn Contact Lenses?  Yes No  If So, What Type?
Autoimmune Disease		Are You Interested In Contact Lenses?  Yes No
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? <1 Yr. 1-2 3-4 5-6 7-10 11-15 15-20 21-30 >30	Last Blood Sugar	Date
Last A1C   Date

Optomap

Optomap

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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