Crystal PM Patient Forms

Patient Form

Demographics

Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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
Primary Doctor Misc/Guardian
How did you hear about us?

Billing Information
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Medical History/Submit

Eye History:
Tell us about your eye or vision concerns reguarding today's visit: (Blurred Vision, Dry eyes, Red eye, Glaucoma concerns, etc....)
Do you experience any of the following?
Distance Blur         Glare              Flashes            Tearing           Cataracts                     Eye Injury
Near Blur               Burning          Headache        Dryness          Cataract Surgery         Eye Surgery
Light Sensitivity    Redness          Eye Strain       Glaucoma       Double Vision             Itching           
Poor Night Vision  Floaters          Lazy Eye
Last Eye Exam:   Primary Vision Correction:   Age of Glasses:   Planning to get new glasses?
Any other eye history or concerns?
      Occupation:                             What are your Hobbies?
Smoking Status:   Type:   How Long:
Prefer Language                   Ethnicity:                Race:
     Height: (feet)    (inches)   Weight:
If you are a diabetic, please answer the following:
Glucometry:   Last Taken   HbA1C   Taken:
Your Current Diabetic therapy:     How would you report your Diabetic Control?
Health History:
Please list your Medical conditions: (Such as: Allergies, Arthritis, Back Problems, Cancer, Diabetes, HBP, etc....
   
Have you had any recent Injuries, Surgeries, or Hospitalization?
Pregnant Or Nursing:
Who is your Primary Care Physician? When was your Last Visit?
Review of your over all Health:

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

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

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

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

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

SKIN: growths, rashes, acne

NEUROLOGICAL: Headaches, migraines, seizures

PSYCHIATRIC: Depression, Anxiety, Insomnia

ENDORCRINE: Thyroid, Diabetes

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

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

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
Medications:
Eye Medications, prescribed and over the counter:

Please list all other medications:

List any allergies to medications:

Are you taking any over the counter medications? (Aspirin, Acetomenophin, Ibuprofen, etc...)

Vitamins: (A, C, E,Zinc, Xanten, Lutein, Fish oil, etc....
Family Eye History:
Cataracts:                  Glaucoma:   Macular Degeneration:   Retinal Detachment:
 Lazy eye:   Blindness/vision loss:                 Hypertension:                   Diabetic:
Family Medical History:
Do you have a family history of Diabetes, HBP, Cancer, Cardiovascular Disease, Athritis, Kidney Disease, Lupus or Thyroid?
                                   
Type in any others:          
Submit Data:

                                                              After completing all the forms, submit the data by pressing "Submit Data" below.