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Demographics

General Information
  Title First Last MI Suffix Nickname
Address:
City: State Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Email:
Birthday: (mm-dd-yyyy)
SSN:
Sex: Male Female
Email:
Occupation:
Employment Status: Employed Full-Time Student Part-Time Student
Marital Status:
Employer/School Name:
Primary Doctor:
Misc/Guardian:
Billing Information
  Is The Billing Address the Same?
  Title First Last MI Suffix Nickname
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Insurance 1

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:
Employer/School:

Insurance 2

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:
Employer/School:

Medical History

Your Medical Profile
Referred By:
Accompanied by:
Relationship:
Marital status:
Ethnicity
Employer/School:
Patient of ours
Occupation/Grade in school
Hobbies:
Medications:
Allergies:
Past medical history:
Diabetic Insulin
Year diagnosed:
Last BS:
Date:
Last A1C:
Date:
Notes:
OTC supplements:
Tobacco use:
Year started:
Alcohol use:
Illegal Drugs:
Pregnant Or Nursing:
Due date/DOB:
Family Medical History
Any family member suffering from the following:
No Problems Diabetes High Blood Pressure Cancer
Relationship:
Any family member suffering from the following eye problems:
Glaucoma Amblyopia Cataracts Macular Degeneration Strabismus (eye turn)
Relationship:

Visual History

Visual History
Have you ever been diagnosed of any of the following:   If yes, what eye?
Yes No Right Left
Glaucoma
Amblyopia (lazy eye)
Cataract
Infalmmatory disorder
Retinal problems
Macular degeneration
Strabismus
Patching
Eye surgery (LASIK/cataract/retinal) Date:
Do you sometimes experience dry eyes
Are your eyes sensitive ti sunlight?
Do you work at a computer?
Do you want information on LASIK surgery?
Notes:
Chief medical complaint
Please select all that apply:
Loss of vision Blurred vision Double vision Floaters
Crossed eyes Flashes of light Eye pain/soreness Watery eyes
Sandy/gritty feeling Glare Light sensitivity Tired eyes
Dry eyes Red eyes Burning/itching
Can you explain in your own words the reason for your visit today:
Which eye has the problem? Right Left Both
Is it new, ongoing, or returning? New Ongoing Returning
How is it effecting you?? Bothersome Aware Painful
Associated with: Infection Medical condition Injury Surgery
How severe is the problem? Mild Moderate Severe
Anything help improve or worsen symptoms? Drops Medication  Other:

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