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Demographics

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

Address:
City:		State/ZipCode	TX 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 UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Never Married Married Legally Separated Divorced Widowed Domestic partner	Employer/School Name
Misc/Guardian		How did you hear about us?	Existing patient Email Marketing Google Advertisement Google Search Google Search Google Reviews Yelp Insurance Website Word of Mouth Other

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	TX 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 UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

These initial questions are required to meet the Government meaningful use criteria for electronic records and will only be used for that purpose.

Preferred Language english spanish Patient Declined to Specify Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify

Height - feet In Weight Have you had a flu shot? yes no

Welcome to Our Office-Please fill out all applicable fields

VISUAL HISTORY:
Briefly describe the main reason for having an examination today:


Associated: Do you have any other symptoms related to this?


I currently wear glasses:   Full-time    Part-time  

If part-time, how often/when? Occasionally Driving Reading / Computer After contact lens removal 1-2 times per week Half time Sports Weekends Social activities   

I currently wear contacts:   Full-time    Part-time             Soft     Rigid Gas Permeable

If part-time, how often/when? Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities        



Contact Lens Wearers:

Current Brand:  Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material        Are your lenses comfortable?  Yes    No   
 
How old is your current pair? new 1-2 weeks 2-4 weeks very old        What is your replacement schedule?     Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly       What solution do you use?    None Optifree Replenish Optifree Pure Moist Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph



Please list all eyedrops you use (OTC and Rx):            How often used?: daily occasionally rarely


Do you have a history of any of the following?                                            Are you currently experiencing any of the following?
            SET ALL TO NO                                                                                       SET ALL TO NO
 
                                      YES NO                                                                    YES  NO                                                   YES NO
                    Blindness                                                       Headaches                                               Eyes itch    

Eye Turn (Strabismus)                                                   Blurred Vision                                             Eyes burn       

Lazy Eye (Amblyopia)                                                   Double Vision                                              Eyes tear    

              Keratoconus                                          Eyes "hurt" or "tired"                                         Eyes feel dry    

                  Glaucoma                                             Halos around lights                            Eyes feel sandy/gritty     

                   Cataracts                                Bothered by light / sun light                                        Flashing lights    

Macular Degeneration                                                   Frequent styes                                                Floaters    

     Retinal Detachment                                           Eyes frequently red        


List any eye surgeries:                                                           Other eye disease or condition                                              Describe any eye injuries: 
                                                          

How many hours a day do you use a computer?        Describe any visual symptoms from computer use:    
<2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours                                                         none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision

 ____________________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY / REVIEW OF SYSTEMS: 
 
Physician's Name:       Last Visit Date:   

List all medications you are currently taking (including any OTC/vitamins):                    List any medications you are allergic to: 
                       

 
Are you pregnant or nursing? Yes    No              If yes, what is the due/birth date?   

Do you have, or ever had, any CHRONIC problems in the following areas?SET ALL TO NO 

                            YES  NO                                               YES  NO                           YES NO
            Migraines                     High blood pressure                   Arthritis     
  
Multiple Sclerosis                       Allergies/Hay fever                    Stroke      

             Diabetes                                         Asthma                   Anemia      

Thyroid problems                                  Emphysema                    Cancer         
   

Notes:

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FAMILY HISTORY

Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)? SET ALL TO NO 

                                            YES No    RELATIONSHIP TO PATIENT                                             YES NO    RELATIONSHIP TO PATIENT     
                        Poor Vision          Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                                        Cancer              Mother Father Sister Brother Aunt Uncle Grandmother Grandfather   
  
                             Blindness          Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                                      Diabetes             Mother Father Sister Brother Aunt Uncle Grandmother Grandfather        

          Eye turn (Strabismus)         Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                          High Blood Pressure         Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
  
        Lazy Eye (Amblyopia)           Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                                         Stroke            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

                          Glaucoma            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                           Thyroid Disease             Mother Father Sister Brother Aunt Uncle Grandmother Grandfather    
               
                           Cataracts            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                         Inherited Disease             Mother Father Sister Brother Aunt Uncle Grandmother Grandfather  
                                                                                                
         Macular Degeneration           Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                              what disease?    

Retinal Detachment/Disease            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

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SOCIAL HISTORY (confidential)

How often do you smoke/use tobacco products?   Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked
 
How often do you consume alcohol?     Never Occasionally Daily         

Do you have? HIV    Hepatitis   STDs

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Who referred you to our office?     

If not referred, how did you hear about Pearson Eyecare Group?    Family member Insurance list Coworker Friend Primary Care Doctor Internet Walk by

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