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

How did you first hear about our office?

Yellow Pages Friend/Relative
Insurance Plan Who?

MEDICAL HISTORY
AllergiesArthritisHeart Disease
AsthmaCancerSkin Disorder
DiabetesCataractsHigh Blood Pressure
Eye InjuryEye SurgeryGlaucoma
NervesKidney 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 Examxx/xx/xxxx
Name of Last Eye Doctor
Date of Last Physical Examxx/xx/xxxx
Name of Physician

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

Do you experience........(check those that apply)
BurningUncomfortable Glasses
ItchinessSudden loss of vision
NauseaSensitivity to light
Watery EyesFainting or dizziness
Double VisionBlurry distance vision
Flashes of LightBlurry near vision
Glare or ReflectionGritty feeling in eyes
SorenessObjects floating in vision
Eye StrainTrouble seeing at night
HeadachesDryness
RednessOther

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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