WELCOME BACK TO OUR OFFICE
 
fields marked with an "*" are required
Name *
Today's Date mm/dd/yyyy
Spouse or Parent *
Mailing Address *
City *
State/Province * Zip/Postal Code *
Date of Birth mm/dd/yyyy *
Age *
Sex: Male
Female
Home Phone xxx-xxx-xxxx *
Work Phone xxx-xxx-xxxx *
Social Security # xxx-xx-xxxx *
Email Address
(for patient communication only)

MEDICAL HISTORY
Allergies Arthritis Heart Disease
Asthma Cancer Skin Disorder
Diabetes Cataracts High Blood Pressure
Eye Injury Eye Surgery Glaucoma
Nerves Kidney Problems
Other

CURRENT MEDICATIONS
(Rx or over the counter)
Medication Name
Antihistamines
Blood Pressure Pills
Diuretic (water pill)
Oral Contraceptives
Sleeping Tablets
Eye Drops
Others
Allergies to Medications
Date of Last Eye Exam xx/xx/xxxx
Name of Last Eye Doctor
Date of Last Physical Exam xx/xx/xxxx
Name of Physician

FAMILY MEDICAL HISTORY
Relationship to you
Blindness
Glaucoma
Diabetes
High Cholesteral
Other

SOCIAL HISTORY
This information is kept strictly confidential. However, you may discuss this portion with the doctor if you prefer. This information is important for medical purposes as well as compliance with insurance directives.
Would prefer to discuss your Social History information with your doctor?
Yes No
Do you use tobacco products?
YES NO
Do you drink alcohol?
YES NO

Employer (or School)
Occupation (or Grade)
What is the major purpose of this visit?
Any problems with your present contact lenses or glasses?

Vision Insurance Medicare Medicaid
VSP Blue Cross
Flex Plan
Other

How will you settle your account?
Check Financing Credit Card Insurance Cash

Do you experience........ (check those that apply)
Burning Uncomfortable Glasses
Itchiness Sudden loss of vision
Nausea Sensitivity to light
Watery Eyes Fainting or dizziness
Double Vision Blurry distance vision
Flashes of Light Blurry near vision
Glare or Reflection Gritty feeling in eyes
Soreness Objects floating in vision
Eye Strain Trouble seeing at night
Headaches Dryness
Redness Other

VISUAL NEEDS

Do You........ (check the box if your answer is yes)
Work on a computer for long periods of time?
Have only one pair of glasses?
Want information on thinner, lighter lenses?
Wear bifocals?
Want information on "no line" bifocals?
Prefer not to wear your glasses at times?
Spend a lot of time outdoors?
Ever find a need for prescription sunglasses?
Have problems with glare or reflections (ex: night driving)?
Do work requiring safety glasses?
Participate in sports? What?
Want more information about corrective vision surgery?
Wear or ever tried wearing contacts?
What kind?

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