Demographics

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

Address:

Apt/Suite #:

City:

State:

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 ZipCode:

Home Phone:	Work Phone:
Cell Phone:	Preferred Contact Method:
	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN	Email
Birthday	Occupation
Sex	Employment Status
Male Female	Employed Full-Time Student Part-Time Student
Marital Status	Employer/School Name
Unknown Single Married Separated Divorced Widowed Child
Doctor Preference	Misc/Guardian
No Doctor Assigned Dr. Hamilton, Brett W. Dr. Quitanilla Maria Dr. Sexton,Ray
How did you hear about us?	Name of who referred you:
Online Friend/Family Advertisement Facebook Insurance Walk In Drive By

Billing Information (If Different)

Address Same As Above

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

Address: Apt/Suite #:

City:

State

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

ZipCode

Home Phone:	Work Phone:

Chief Complaint

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Chief Complaint

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Reason for Visit:

Secondary Reasons:

Blurred vision Distance vision blurry Near vision blurry vision blurry distance and near wants to be fitted for contacts needs new glasses needs more contacts red eye pain in eye loss of vision injury to eye itching burning stinging dry eyes Diabetic eye exam annual doctor directed diabetic eye exam broken glasses Lost RX failed screening at school failed screening at pediatrician's office Physician directed eye exam Complete eye exam to rule out problems Other

Review of Ocular System

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Ocular History:	Eye Meds:
None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink

Last Eye Exam:	Doctor:
1 year 2 years 3 years Other	Never Here Doesn't Remember Barton Creek Lenscrafters Eyemasters Other

Primary Vision Correction	Do you have back up specs?	Do you want new glasses?
None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other	No Yes Other	Yes No Other

Type of CLs worn in past	Cleaner	Disposal
None Disposable Conventional Colored RGP PMMA Cobalt Study Lens Soft Other	None PureMoist Optifree Clear Care Boston Renu Biotrue Aquify Other	daily 2 weeks monthly weekly yearly Other

Wear Time	Days per Week	Hours Worn Comfortably
>2 hours today All day Occ. Overnight Extended 8 hours 10 hours 12 hours Overnight Other

Family Ocular History

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Glaucoma	Cataracts	Macular Degen	Retinal Detach	Crossed / Lazy
No Parents Sibling Grandparent Other	No Parents Siblings Grandparent Other	No Parents Siblings Grandparent Other	No Parents Siblings Grandparent Other	No Parents Siblings Grandparent Other

Medical History

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Medical History

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Primary Care Physician	Last Visit	Reason for Visit
	1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other	Check up Annual Specific Other

Vitamins	Over The Counter	Pregnant or Nursing
None A E C Zinc Xanten Lutein Other	None Asprin Acetomenophin Ibuprofen Other	No Yes Unsure Other

Current Medications	Drug Allergies

Injuries, Surgeries, Hospitalization

Family Medical History

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Please choose from the drop down medical issues that have occured within your family. If there are multiple, please type these in the extra text boxes provided. Thank you!

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you! None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Hypertension Other
           

Social History

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Occupation	Hobbies
	None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Tobacco Use	Alcohol Use	Illegal Drugs
Never smoker ( < 100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker ( < 10 cigs/day) Heavy smoker ( > 10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	No Yes Occasionally Socially Other	No Yes Other

Review of Systems

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Do you currently have any of these problems?

General	Ear, Nose, Throat	Cardiovascular
none fatigue fever loss of appetite weight gain weight loss Other	none chronic cough congestion daytime drowsiness dry throat / mouth gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache Other	none chest pain heart disease high cholesterol hypertension racing heartbeat shortness of breath swollen feet/ankles vascular disease Other

Respiratory	Genitourinary	Musculoskeletal
none asthma cronchitis cyanosis emphysema productive cough shortness of breath wheezing Other	none impotence jaundice overactive bladder painful urination underactive bladder urgency in urination urinary incontinence Other	none arthritis decreased range of motion muscle cramps pain/tenderness stiffness swelling weakness Other

Skin	Neurological	Psychiatric
none acne eczema itching psoriasis rosacea Other	none balance problems changes in senses dementia memory problems muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Other	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other

Endocrine	Blood/Lymph	Allergic/Immunologic
none diabetes hypothyroid hyperthyroid Other	none anemia bleeding gums cuts slow to clot easy bruising hx of significant blood loss nosebleeds pale skin pounding in ears rapid heartbeat shortness of breath Other	none asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other

Gastrointestinal

none abdominal pain acid reflux bloody stools constipation Crohn's disease dark urine diarrhea gastric reflux (GERD) IBS jaundice nausea ulcer vomiting Other

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