Welcome to Woodbridge Eye Care!

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Preferred Language

English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Vision Insurance

Insurance information

Insurance Name:	None Advantica Availity Avesis Block Vision Blue Cross Blue Shield Cigna (VSP) Davis Vision Eye Care Network/MES Humana Medicare NVA Opticare Optum Health (Spectera/UHC) Safeguard Superior Vision SVS UHC Great West United Healthcare United Healthcare AARP VSP
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 Insurance

Insurance Information

Insurance Name:	None Advantica Availity Avesis Block Vision Blue Cross Blue Shield Cigna (VSP) Davis Vision Eye Care Network/MES Humana Medicare NVA Opticare Optum Health (Spectera/UHC) Safeguard Superior Vision SVS UHC Great West United Healthcare United Healthcare AARP VSP
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

PRIMARY CARE PHYSICIAN:

Last Visit:

Pregnant or Nursing

No Yes Unsure

OTC medications

Vitamins:

PATIENT MEDICAL HISTORY: Headaches, Arthritis, Asthma, Diabetes, High Blood Pressure, Heart, Infl. Bowel Dz, Seizures, Thyroid, etc.

Injuries, Surgeries, Hospitalization

Do you have Diabetes?

No Yes

If yes, what is your treatment?

Diet Medications Insulin

When were you diagnosed?

Last Blood Sugar Reading?

Latest HbA1c?

Do you drink alcohol?

No Yes Occasionally Socially

Are you a smoker?

Non smoker Current every day smoker Current some day smoker Former smoker Unknown if ever smoked

Do you do illegal drugs?

No Yes

Whom may we thank for referring you?

Review of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?

None Negative Other

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

None HTN High BP Surgery Heart Disease Vascular Disease High Cholesterol Other

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis COPD Emphysema Other

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence

None Painful urination Frequent urination Impotence Jaundice Kidney stones Incontinence Bladder infection Other

MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury

None Joint pain Stiffness Swelling Cramps Arthritis Other

SKIN: growths, rashes, acne

None acne growths melanoma rash roscea warts Other

NEUROLOGICAL: Headaches, migraines, seizures

None numbness, paralysis headache head trauma seizures migraines Other

PSYCHIATRIC: Depression, Anxiety, Insomnia

None Alzheimer's Anxiety Bipolar Depression Insomnia Schizophrenia Other

ENDOCRINE: Thyroid, Diabetes

None Diabetes Type 2 Diabetes Type 1 Hypothyroidism Hyperthyroidism Thyroidectomy Other

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

None Anemia Bleeding Cholesterolemia Dislipidemia Other

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Lupus

None Itching Sneezing Swelling Redness Hives Lupus Rheumatoid Arthritis Seasonal allergies Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Other

Ocular History

CHIEF COMPLAINT

Location (where?)

right eye left eye both eyes Other

Duration (how long?)

constant intermittent few months one year few weeks Other

Quality (does it cause vision loss or blur?)

blur vision loss neither Other

Severity of symptoms

mild moderate severe Other

Context (did symptoms occur suddenly or gradually?)

suddenly gradually Other

Modifying factors (does anything help Sxs?)

squinting closing eyes wearing glasses artificial tears Other

Timing (is it getting better or worse?)

same better worse Other

OTHER COMPLAINTS

PATIENT OCULAR HISTORY: Injuries, Infections, Surgeries, Diseases, Etc.

Current eye medications:

Last Eye Exam:

Last Eye Doctor:

Do you have Glaucoma?

No Yes

Cataracts?

No Yes

Macular Degeneration?

No Yes

Retinal Detachment?

No Yes

Crossed / Lazy eye?

No Yes

Do you wear glasses?

Yes No

If yes, what type?

Single vision Bifocal Progressives Trifocal OTC Readers

Do you wear contacts?

Yes No

Type of contact lenses

FAMILY OCULAR HISTORY: Please list all conditions (glaucoma, cataracts, macular degeneration, etc.)

What is your visit for today?

Glasses Contacts Glasses & Contacts First eye exam Medical visit

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