Demographics

Patient Information
TitleFirstMILastNickname
AddressCityStateZip
Home PhoneCell PhoneWork PhoneOther Phone
EmailPreferred Contact Method
SSN Birthday (mm/dd/yyyy) Marital Status Sex
Male   Female
Occupation Employer / School Name
Employment Status
Employed   F/T Student   P/T Student
Other information, (Ex: Guardian name)




Medical History

Are you experiencing or have been diagnosed with any of the following?
General
None
Fatigue
Fever
Weight Gain
Weight Loss
Other
Illness or pain
None
Dry throat / mouth
Headache
Sleep apnea
Arthritis
Other
Cardiovascular conditions
None
Heart disease
High Cholesterol
Hypertension
Stroke
Other
Respiratory conditions
None
Asthma
Emphysema
Chronic cough
Other
Mental disorders
None
Anxiety
Bipolar
Depression
Other
Endocrine system disorders
None
Diabetes
Hypothyroid
Hyperthoyroid
Other
Urinary conditions
None
Painful urination
Blood in urine
Other
Muscular system disorders
None
Pain/tenderness
Weakness
Other
Digestive system conditions
None
Acid reflux
Inflamatory Bowel Syndrome
Other
Skin conditions
None
Psoriasis
Rosacea
Allergic dermatitis
Other
Nervous system conditions
None
Memory problems
Numbness, paralysis
Tremors
Other
Reproductive system disorders
None
Breast cancer
Prostate cancer
Ovarian cancer
Other
Blood / Lymphatic disorders
None
Anemia
History of blood loss
Cuts slow to clot
Other
 
Do you smoke?
Do you drink alcohold daily?
Do you use recreational drugs?
Please list ALL medications you are taking
Are you allergic to any medications?
Primary care physician?
Name/City/Medical Center:
How long ago last visited?
Previous eye doctor
Name/City/Medical Center:
How long ago last exam?
Family history
Glaucoma
No
Parents
Sibling
Grandparents
Other
Cataracts
No
Parents
Sibling
Grandparents
Other
Macular Degeneration
No
Parents
Sibling
Grandparents
Other
Retinal Detachment
No
Parents
Sibling
Grandparents
Other
Other eye diseases
Have you ever been diagnosed or had any of the following?
Glaucoma
Cataracts
Amblyopia
Macular Digeneration
Eye Turn
Retinal Detachment
Keratokonus
Eye surgery
Other
Vision correction
Primary vision correction

Type of contact lenses, if any

Complete Check-in

How did you hear about us?:
If other or friend/family referral, who?: