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General Information
First Name
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Last Name:
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M.I.
Sex:
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Male
Female
Street or P.O. Address:
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City:
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State:
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip:
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Date of Birth:
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Cell Phone #:
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Home Phone #:
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Soc. Sec. #:
Email Address:
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Employer:
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Occupation:
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Date of Last Eye Exam:
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Where did you get your last eye exam?
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Date of Last Physical Exam:
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Name of Primary Care Physician:
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Height
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Weight
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Conditions
Do you experience any of the following?
Blurred vision
Dryness
Excessive tearing
Sudden loss of vision
Burning
Eye/Eyelid infection
Flashes of light
Itching
Loss of side vision
Drooping Eyelid
Floaters in vision
Contact lens irritation
Other
Other
Are you pregnant?
Yes
No
Eyeglass History
Do you wear glasses?
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Never
Full-Time
Part-Time
Distance Only
Near Work Only
Do you use a computer?
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Yes
No
If so, how many
hours per day?
1-2
2-4
4-6
6-8
8+
Are you interested in contact lens wear?
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Yes
Yes, if the doctor thinks I'm a good candidate
No
Medical History
Have you ever had any EYE DISEASE? (e.g., glaucoma,
cataracts, wandering or "lazy" eye, retinal detachment)
*
Yes
No
If YES, please explain:
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Have you ever had any SURGERY for your eyes or any other condition?
*
Yes
No
If YES, please explain:
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Do you take any MEDICATIONS (including vitamins/supplements)?
*
Yes
No
If YES, please list:
*
Do you have any drug or food ALLERGIES?
*
Yes
No
If YES, please explain:
*
Do you currently have any of the following conditions?
Allergic/Immunologic (e.g. Drug Allergy, Rheumatoid Arthritis, Lupus)?
*
Yes
No
If YES, please explain:
*
Musculoskeletal (e.g. Fibromayalgia, Osteoarthritis, Anklyosis Spondylitis)?
*
Yes
No
If YES, please explain:
*
Cardiovascular (e.g., Heart Disease, Hypertension, Stroke, Vascular disease)?
*
Yes
No
If YES, please explain:
*
Gastrointestinal (e.g. Crohn's, Colitis, Ulcer, Digestive)?
*
Yes
No
If YES, please explain:
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Neurological (e.g., MS, Epilepsy, Alzheimers, Parkinsons)?
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Yes
No
If YES, please explain:
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Constitutional (e.g., Developmental Disability, Weight Loss, Fever, Fatigue, Trauma)?
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Yes
No
If YES, please explain:
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Genitourinary (e.g. STD, Viral Herpetic, Chlamydia)?
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Yes
No
If YES, please explain:
*
Psychiatric (e.g., Depression, Panic Disorder)?
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Yes
No
If YES, please explain:
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Ear, Nose, Mouth & Throat (e.g., Ear Ache, Sore Throat, Tinnitis)?
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Yes
No
If YES, please explain:
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Hematologic/Lymphatic (e.g., Anemia, Leukemia, Large Blood Loss)?
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Yes
No
If YES, please explain:
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Respiratory (e.g., Asthma, Bronchitis, Emphysema)?
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Yes
No
If YES, please explain:
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Endocrine (e.g., Diabetes, Thyroid, Hormonal dysfunction)?
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Yes
No
If YES, please explain:
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Integumentary (e.g., Eczema, Rosacea, Psoriasis)?
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Yes
No
If YES, please explain:
*
Please list any additional conditions not listed above.
*
Family/Social History
Do you consume alcohol?
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Never
Occasionally
1 drink per day
2-3 drinks per day
4+ drinks per day
Do you smoke?
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Never
Occasionally
1/2 pack per day
1 pack per day
1+ pack per day
Enter the word in the image
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