"*" indicates required fields Patient Info Date* MM slash DD slash YYYY Last Name First Name Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone*What is your Gender?* Male Female Social Security Number* Vision insurances require social security number to determine eligibility. This information must be entered prior to your visit or you will experience a delay during the time of your visit. All parts of this form are secure and encrypted.Occupation Eye History Referred by Name of Previous Doctor Reason for VisitDo you have/have you had any of the following Dry Eyes Eye Surgery Cataracts Retinal Problems Strabismus (Eye Turn) Itchy Eyes Eye Injury Glaucoma Macular Degeneration Amblyopia (Lazy Eye) Flashes Floaters Blurred Vision Even With Glasses/Contact Lenses Please explain any checked boxes Medical History Are you currently taking any medication?* Yes No If so, please list:Do you have any medication allergies?* Yes No If so, please list:Do you have any medication allergies?* Yes No Not sure If so, please list:Check the conditions that apply to you: Environmental Allergies Diabetes Dry Mouth Lupus High Blood Pressure Thyroid Disease Sinus Problems Dry Skin Heart Disease Gastrointestinal Disease HIV/AIDS Arthritis/Joint Pain Stroke Cancer Please explain any checked boxesCheck the symptoms that you have experienced in the PAST 6 WEEKS Fever/Chills Unexplained change in weight Fatigue/Malaise/Generalized weakness Headaches/Migraines Dizziness Sinus Pain/Pressure/Discharge Excessive snoring Wheezing/Chronic Cough Shortness of breath Chest pain, pressure or tightness Swelling of hands/feet/ankles Nausea/Vomiting Abdominal pain Heartburn Stiffness/Pain in joints/muscles Joint swelling Bleeding/Easy bruising Excessive urination Excessive thirst/hunger Hot flashes Rash Anxiety/Panic Attacks Insomnia/Problems with Sleep Loss of energy Do you use or do you have history of using tobacco? Yes No Do you use or do you have history of using illegal drugs? Yes No How often do you consume alcohol? Daily Weekly Monthly Occasionally Never Family History Does anyone in the family have: Dry Eyes Retinal Problems Strabismus (Eye Turn) Glaucoma Macular Degeneration Amblyopia (Lazy Eye) If so, who in the family?Does Anyone in the Family Have: Diabetes Lupus High Blood Pressure Thyroid Disease Heart Disease Gastrointestinal Disease Arthritis/Joint Pain Stroke Cancer If so, who in the family?Patient Initials:* Patient Date of Birth Month Day Year * First Last NameThis field is for validation purposes and should be left unchanged.
