Crystal PM Patient Forms

Demographics

General Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer/School Name

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Please answer the following to allow us to serve you better Are you currently having any vision problems? If yes, Explain:
Do you have questions concerning laser vision correction?
Are you thinking about getting new glasses today? D you wear contact lenses?
Primary Medical Physician:
Do you smoke: Authorization & Release (HIPAA & ABN)Initial
Race: Ethnicity: Preferred Language:
Please list your Prescription Medications: No current Medications

Please list your Drug Allergies: No known drug Allergies

List your Over The Ccounter medications:
List the Vitamins you take:
Injuries, Surgeries, Hospitalization:

Reason for visit?

REVIEW OF OCULAR SYSTEM Select any conditions you may have:
Last Eye Exam: Who was the doctor? Current Eye Medications:

FAMILY OCULAR HISTORY (please select if any family member has the condition below)

Crossed/Lazy Eyes:		Retinal Detachment:		Macular Degeneration:
Cataracts:		Glaucoma:

Family History (IS THIS REDUNDANT?) SET ALL TO NO

CONDITION			RELATIONSHIP TO YOU
BLINDNESS	No	Yes
GLACOMA	No	Yes
CATARACTS	No	Yes
MACULAR DEGENERATION	No	Yes
DIABETES	No	Yes
HYPERTENTION	No	Yes
CANCER	No	Yes
HEART DISEASE	No	Yes
AMBLYOPIA (LAZY EYE)	No	Yes
STABISMUS (CROSSED EYES)	No	Yes
RETINAL DETACHMENT	No	Yes
OTHER	No	Yes

AUTO-LENSOMETRY / PREVIOUS CORRECTION Primary vision correction: Backup Glasses? Planning to get new glasses?
Type of Contacts worn? Wear Time? How often do you dispose them? Type of Cleaner?

REVIEW OF SYSTEMS DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS? SET ALL TO NO

CONSTITUTIONAL: Fever, weight loss, weight gain, fatigue?	No	Yes
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	No	Yes
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	No	Yes
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	No	Yes
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	No	Yes
GENITONURINARY: Kidney Stones, Frequent Urination, impotence	No	Yes
MUSCULOSKELETAL: Arthritis, Joint Pains, Head or Neck Injury	No	Yes
INTEGUMENTARY: growths, rashes, acne	No	Yes
PSYCHIATRIC: Depression, Anxiety, Insomnia	No	Yes
ENDORCRINE: Thyroid, Diabetes	No	Yes
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	No	Yes
HEMATOLOGIC/LYMPHATIC: Anemia, cholesterol, bleeding problems	No	Yes
NEUROLOGICAL: Headaches, migraines, seizures	No	Yes

Please list any additional notes:

SOCIAL HISTORY

Tabacco:		Type:		How Long:
Alcohol:		Type:		How Long:

Do you drive? If Yes, do you have difficulty driving at night?
How many hours do you spend on the computer?
What are your leisure activities?
Do you have a backup pair of glasses?

Submit Data

Are you sure all of the information you gave us is correct? If so, please click Submit Data below.

Please bring your driver lincense, all your insurance cards, and any glasses you wear to your appointment.