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First Name Last Name Middle Initial Date of Birth Age
 
 
Street Address / PO Box City State ZIP SSN (Last 4)
 
 
Sex Marital Status E-Mail Address Home Phone Cell Phone
M F
 
 
First Visit? Reason for Current Visit Last Eye Exam Date Referred By
Yes No
 
 
Employment Status Employer Emp. Phone Occupation
 
 
Employer Street Employer City Emp. State Emp. ZIP
 
  Other Contact Information  
 
Person responsible for charges (if not patient) Relationship To Patient Home Phone Work Phone
 
 
Who should we contact in case of an emergency? Relationship To Patient Home Phone Work Phone
 
  Eye-Health - Patient ( check all that apply )  
 
  Amblyopia (Lazy Eye) Eye Surgeries Itchy Feeling
  Blurred Vision - Far Eye Turn Infection of Eye / Lid
  Blurred Vision - Near Floaters / Spots Loss of Vision - Central
  Burning Eyes Fluctuating Vision Loss of Vision - Side
  Cataracts Foreign Body Sensation Mucus / Discharge
  Double / Distorted Vision Glaucoma Redness
  Drooping Eyelid Glare / Light Sensitivity Retinal Detachment
  Dry Eyes Headaches Tearing / Watery Eyes
 
  General Health - Patient ( check all that apply )  
 
  Allergies / Hay fever Chronic Cough Kidney Disease
  Asthma / Respiratory Diabetes Psychiatric / Depression
  Blood Disorders Emphysema Rheumatoid Arthritis
  Cancer Gastrointestinal Problems Thyroid / Endocrine Disease
  Cardiovascular / High B.P. Heart Attack / Stroke Skin Disorders
  Chronic Bronchitis Headaches / Migraines Weight Loss / Gain
 
  Family History - Blood Relatives ( check all that apply )  
 
  Amblyopia (Lazy Eye) Color Blindness High Cholesterol
  Arthritis Diabetes Macular Degeneration
  Blindness Eye Turn Retinal Detachment
  Cancer Glaucoma Stroke / Heart Attack
Cataract(s) High Blood Pressure Thyroid Disease
 
 
Family Physician - Physician's Name Physician's Phone Last Medical Exam Date  
 
 
  Medications - Enter all medications taken by patient ... and for what condition each is taken.  
 
  Medication Condition   Medication Condition
1. 2.
3. 4.
5. 6.
7. 8.
 
 
Enter the name of all medications (or substances) to which the patient is allergic.
 
 
  Please Answer The Following Questions  
 
Are you pregnant or nursing? Yes No Do you have trouble driving at night? Yes No
 
 
Do you wear glasses? Yes No Contacts? Yes No If Contacts, Type    
 
 
Do you experience blur, headaches or eyestrain with computer use? Yes No  
 
 
Are you interested in laser (refractive) surgery to correct your vision? Yes No I have Questions
 
 
 
  Vision Insurance Information    
 
Insurance Company
Primary Insured's Sex M F
Patient's Relationship to Insured

»  Self

Spouse

Child

Other

 
Insured's ID # 
 Group # Insured's Date of Birth
Insured's Name 
Insured's Phone
 
 
 
  Other Insurance Information    
 

Insurance Company 

2nd Insured's Sex M F
Patient's Relationship to Insured

»  Self

Spouse

Child

Other

 
Insured's ID # 
 Group # Insured's Date of Birth
Insured's Name 
Insured's Phone
 
  Please enter any comments or additional Information we should know.