General Information

First Name *

Last Name: *

M.I.

Salutation: *

Sex: *

Street or P.O. Address: *

City: *

State: *

Zip: *

Date of Birth: *

Age: *

Cell Phone #: *

Home Phone #, if different: *

Soc. Sec. #:

Email Address: *

Employer: *

Occupation: *

How were you referred to our office? *

If you were referred by an individual, would you like to tell us who it was?

Insurance Information

VISION PLAN INFO MAJOR MEDICAL INSURANCE

Insurance Company Name: *

Insurance ID #:

Employer:

Group Number:

Name of Policy Holder:

Insured's Date of Birth:

Insured's Social Security #:

Patient's Relationship to Insured:

Eyeglass History

Do you wear glasses? *

What type of glasses do you own? *

Do you use a computer, tablet, and/or cell phone screens? *

Yes

No

If so, how many
hours per day?

How many inches are your eyes
from your monitor?

How many computer monitors?

*

	Yes	No
Do you have problems with glare while driving?	Yes	No
Do you have problems with night vision while driving?	Yes	No
Are you allergic to nickel?	Yes	No
Do your sunglasses have UV (ultra-violet) protection?	Yes	No
Are your sunglasses your current prescription?	Yes	No

Contact Lens History

*

	Yes	No
Do you currently wear contact lenses?	Yes	No
Have you ever tried to wear contact lenses?	Yes	No
If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?	Yes	No
Are you having any problems with your current contacts?	Yes	No

Answer the questions below ONLY IF you currently wear contact lenses:

What type or brand of contacts do you wear?

Do you currently wear daily, bi-weekly, or monthly contact lenses?

How often do you replace or dispose of your contact lenses?

What brand of solution do your lenses soak in overnight?

	Hours/Day	Days/Week
What is your typical contacts wearing schedule?	Hours/Day	Days/Week

	Yes	No
Would you like to be evaluated for refractive laser surgery?	Yes	No

Medical History

Date of Last Eye Exam: *

Where did you get your last eye exam? *

Date of Last Physical Exam: *

Name of Primary Care Physician: *

Do you suffer from: *

	Yes	No
Headaches?	Yes	No
Glare?	Yes	No
Light Sensitivity?	Yes	No
Tired Eyes?	Yes	No
Amblyopia (lazy eye)?	Yes	No
Burning?	Yes	No
Dryness?	Yes	No
Epiphora (excess tearing)?	Yes	No
Eye Pain or Soreness?	Yes	No

*

	Yes	No
Foreign Body Sensation?	Yes	No
Infection of Eye or Lid?	Yes	No
Itching?	Yes	No
Mucous Discharge?	Yes	No
Ptosis (drooping eyelid)?	Yes	No
Redness?	Yes	No
Sandy or Gritty Feeling?	Yes	No
Strabismus (crossed eyes)?	Yes	No

*

	Yes	No
Blurred Distance Vision?	Yes	No
Blurred Near Vision?	Yes	No
Distorted Vision (haloes)?	Yes	No
Double Vision?	Yes	No
Floaters or Spots?	Yes	No
Fluctuating Vision?	Yes	No
Loss of Vision?	Yes	No
Loss of Side Vision?	Yes	No

Many diseases of the body have grave eye health consequences. While the questions below may seem unrelated to your eye health, it is crucial to your care that we ask them.

Have you ever been treated for any MEDICAL CONDITIONS?
(e.g., diabetes, high blood pressure, arthritis) *

Yes

No

If YES, please explain:

Have you ever had any EYE DISEASE? (e.g., glaucoma,
cataracts, wandering or "lazy" eye, retinal detachment) *

Yes

No

If YES, please explain:

Have you ever had any SURGERY for your eyes or any other condition? *

Yes

No

If YES, please explain:

Do you take any MEDICATIONS? *

Yes

No

If YES, please explain:

Do you have any food or drug ALLERGIES? *

Yes

No

If YES, please explain:

Do you currently have any of the following: *

	Yes	No
Chronic fever / unexpected weight loss or gain / fatigue?	Yes	No
Ear/Nose/Throat problems (e.g., hearing loss, sinus problems, sore throat?)	Yes	No
Heart problems (e.g., chest pain, irregular heartbeat, swelling of feet, cold hands/feet?	Yes	No
Respiratory problems (e.g., shortness of breath, wheezing, coughing)?	Yes	No
Gastrointestinal problems (e.g., heartburn, abdominal pain, diarrhea, vomiting)?	Yes	No
Genitournimary problems (e.g., painful urination, blood in urine, sex organ problems)?	Yes	No
Musculoskeletal problems (e.g., muscle aches, joint pain, swollen joints)?	Yes	No
Skin problems (e.g., rashes, excessive dryness, growths or lumps)?	Yes	No
Neurological problems (e.g., numbness, weakness, headaches, blackouts)?	Yes	No
Psychiatric problems (e.g., depression, anxiety)?	Yes	No
Endocrine problems (e.g., frequent urination, thirst, feeling hot or cold much of the time)?	Yes	No
Blood/Lymph problems (e.g., bruising, weakness, unusual paleness, swollen glands	Yes	No
Immune problems (e.g., frequent infections; allergic reactions to foods, dust, pollens)?	Yes	No

If you answered YES to any of the previous questions, please explain:

Family/Social History

Do any MEDICAL (such as cancer, diabetes, HBP) or EYE DISEASES (such as cataracts, glaucoma, macular degeneration) run in your family (blood relatives only)? *

Yes

No

If YES, please explain:

Do you consume alcohol? *

Do you smoke? *

What is your Marital Status? *

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