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Demographics

TitleFirstLastMISuffixNickname
Address: Apt/Suite #:
       City: State: ZipCode:

Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Male
Female
Employed
Full-Time Student
Part-Time Student
 
Marital Status Employer/School Name
Doctor Preference Misc/Guardian
How did you hear about us?

Billing Information (If Different) Address Same As Above

TitleFirstLastMISuffix
Address: Apt/Suite #:
City: State ZipCode

Home Phone: Work Phone:

Chief Complaint


Chief Complaint


Reason for Visit: Secondary Reasons:


Review of Ocular System


Ocular History: Eye Meds:

Last Eye Exam: Doctor:

Primary Vision Correction Do you have back up specs? Do you want new glasses?

Type of CLs worn in past Cleaner Disposal

Wear Time Days per Week Hours Worn Comfortably


Family Ocular History


Glaucoma Cataracts Macular Degen Retinal Detach Crossed / Lazy

Medical History

Medical History


Primary Care Physician Last Visit Reason for Visit

Vitamins Over The Counter Pregnant or Nursing

Current Medications Drug Allergies

Injuries, Surgeries, Hospitalization


Family Medical History


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!


           

Social History


Occupation Hobbies

Tobacco Use Alcohol Use Illegal Drugs


Review of Systems


Do you currently have any of these problems?

General Ear, Nose, Throat Cardiovascular

Respiratory Genitourinary Musculoskeletal

Skin Neurological Psychiatric

Endocrine Blood/Lymph Allergic/Immunologic

Gastrointestinal

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