Demographics

Title First Last MI Suffix Nickname

Address:
City:		State/ZipCode	CA 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 (mm/dd/yyyy):		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Freeland, Michael Dr. Ross, Michael	Misc/Guardian

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Visual History

VISUAL HISTORY
Briefly describe the main reason for having an examination today:

Do you have any other symptoms related to this?

Other eye issues or problems


I currently wear glasses:    None  Full-time  Part-time  What type of glasses? Single Vision Distance Single Vision Reading Progressive Bifocal Trifocal Computer Vision   How old are the glasses? less than 1 year 1 year 2 years older than 2 years
Do you currently wear contacts?: No YesFull-time  Part-time  If part-time, how often/when?  Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities  Type: Soft Rigid Gas Permeable
Contact Lens Wearers:  Are your lenses comfortable? Yes No
What solution do you use?  None Optifree Replenish Optifree Pure Moist Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph Contact Lens Brand:  Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material
Right: Power   Base Curve: 
 Left: Power    Base Curve:
What  is your replacement schedule?  Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly Do you sleep with your contact lenses?  Yes No
If you don't wear contacts are you interested in a trial fitting?  Yes No
Please list all eyedrops you use (OTC and Rx):

How often used?: daily occasionally rarely List any eye surgeries: none Cataract Chalzion LASIK Lid PRK Pterygium Strabismus

Describe any eye injuries:

Do YOU have a history of any of the following?	Are you currently experiencing any of the following?
Blindness	Headaches	Halos around lights
Eye Turn (Strabismus)	Blurred Vision	Bothered by light/sun
Lazy Eye (Amblyopia)	Double Vision	Frequent styes
Keratoconus	Eyes "hurt" or "tired"	Eyes frequently red
Macular Degeneration	Floaters	Eyes itch
Retinal Detachment	Flashing lights	Eyes burn
Glaucoma	Eyes feel sandy/gritty	Eyes tear
Cataracts		Eyes feel dry

 

Other eye disease or condition none Amblyopia Blindness Cataracts Glaucoma Lazy Eye Macular Degeneration Retinal Detachment Strabismus

How many hours a day do you use a computer? 2-4 hrs <2 hrs4-8 hrs >8 hrs
Describe any visual symptoms from computer use: none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision
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Medical History

MEDICAL HISTORY / REVIEW OF SYSTEMS 
Primary Care Physician's Name:  Last Visit Date:
List all medications you are currently taking (including any OTC/vitamins):

Allergies/Alerts: No Known Drug Allergies Chronic Allergies Penicillin Seasonal Sulfa Tetracycline
Are you pregnant or nursing? NoYes    If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas? (CHECK ALL THAT APPLY TO YOU:)

EAR NOSE THROAT	MUSCLES, BONES, JOINTS	ENDOCRINE	IMMUNOLOGIC
Dry Mouth/Throat	Head/Neck injury	Thyroid	Rheumatoid
Allergies/Hay fever	Arthritis	Diabetes	Lupus
Hearing Impaired	Joint Pain	Other	AIDS
Sinus	Other		Other
Other
CARDIOVASCULAR	SKIN	BLOOD/LYMPH	GASTROINTESTINAL
High blood pressure	Growths	Anemia	Acid Reflux
Heart Attack or Surgery	Rashes	Cholesterol	Crohn's/Irritable Bowl
Vascular Disease	Acne	Bleeding Disorder	Ulcer
Stroke	Other	Other	Other
Other
RESPIRATORY	NEUROLOGICAL	PSYCHIATRIC	GENITAL, KIDNEY, BLADDER
Asthma	ADD/ADHD	Anxiety	Kidney Stones or Disease
Bronchitis	Migraines	Depression	Frequent Urination
Emphysema	Seizures	Bipolar	Impotence
COPD	Brain or Spinal injury	Other	Other
Other	Alzheimers
	Other

 

 

 

 

 

 

 

 

 

 

 

 

 
   


List any other medical conditions:

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Family History

FAMILY HISTORY
Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?

		YES	RELATIONSHIP TO PATIENT
Poor Vision			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Blindness			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Eye turn (Strabismus)			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Lazy Eye (Amblyopia)			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Glaucoma			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cataracts			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Macular Degeneration			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Retinal Detachment/Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cancer			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Diabetes			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
High Blood Pressure			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Stroke			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Thyroid Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Other Inherited Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
If yes, what disease?

  

 
  
 
 



  

 





 

 
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Social History

SOCIAL HISTORY (confidential)

How often do you consume alcohol: Never Occasionally Daily   How often do you smoke/use tobacco products? Never Occasionally Daily

Preferred Language: English Spanish Chinese Japanese Other   Race: Caucasian African or African American Hispanic Asian Pacific Islander   Ethnicity:  

Hobbies:

Family Members living at home:
Name:  Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100  Name:   Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Name:  Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100  Name:   Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Name:  Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100  Name:   Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

Who referred you to our office?   If not referred, how did you hear about us? Family member Insurance list Coworker Friend Primary Care Doctor Internet Drove by

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