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Patient information

First name

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Last name

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Nickname

Address

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City

State

Zip Code

Cell Phone

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Birthday

SSN

Occupation

Birth Sex

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How did you hear about us?

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Medical History

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Eye History

Reason for Visit

Please explain reason for visit

Are there any other reason for today's examination?

Do you have any of these eye symptoms or conditions?

Please list any eye medications you are taking

Have you had any eye surgeries? Please describe

Last Eye Exam

Eye Comfort & Skin Wellness

Many patients experience symptoms that affect eye comfort or the delicate skin around the eyes. Please take a moment to answer the following:

Do you frequently experience dry, gritty, burning or irritated eyes? Yes No

Do you notice any of the following that bother you: crow's feet, under-eye bags, sagging jawline, or loose skin? Yes No

Are you interested in learning about non-surgical facial skin tightening or lifting treatments? Yes No

Medical History:

Medications

Over the Counter Medications

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Do you have any of these medical conditions?

Diabetes

Year Diagnosed

HbA1cS

High Cholesterol

Hypertension

Thyroid Conditions

Cancer

Other

Family Medical History

Unknown Family History

Does anyone in your family have any of these medical conditions?

Diabetes

Hypertension

High Cholesterol

Thyroid

Cancer

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Glaucoma

Retinal Detach

Mac Degen

Cataracts

Lazy/Crossed Eye

Blindness

Review Of Systems

General

Ear/Nose/Throat

Cardiovascular

Respiratory

Genitourinary

Musculoskeletal

Gastrointestinal

Skin

Neurological

Psychiatric

Endocrine

Blood/Lymph

Immune

Other

Social History

Hobbies

Smoking Status

Alcohol Use

Race

Ethnicity