Patient Form

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: Cell Phone: SSN (Last 4) Preferred Contact Method: Home Phone Work Phone Cell Phone Other Phone Text Message Email Birthday Email Sex Male Female Occupation Marital Status Divorced Domestic partner Legally Separated Married Never Married Widowed Employment Status Employed Full-Time Student Part-Time Student Misc/Guardian Employer/School Name Primary Doctor No Doctor Assigned Dr. Lewis, Robin Dr. Bacon, Howard B. Dr. extern, Dr. Wright, Daniel G Dr. Tsang, Suzanne Dr. Lewis, Dan

Reason

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Reason for Visit
Referred by
Last Eye Exam
Occupation

Glasses?	Yes No
Contacts?	Yes No
Vision Therapy	Yes No

	Blurry @ Dist
	Blurry @ Near
	Seeing Double
	Avoids Close Work
	Short Attn Vis Tasks
	Hard to remember what is read
	Skip Words, Phrases or Lines of Print
	Losing place when reading or writing
	Spelling Problems
	Using a finger or marker to keep place
	Closer than normal reading dist
	Farther than normal reading dist
	Print blurs after a short time
	Words seem to float around
	Sudden Vision Loss
	Spots or Floaters
	Flashes of light, sparks or stars

	Problems seeing at night
	Colored Halos around lights
	Excessive blinking or rubbing
	Squints frowns or scowls
	Dizziness
	Motion Sickness
	Headaches
	Eyes Dry
	Eyes Red
	Eyes Hurt
	Eyes Itch
	Gritty
	Burn
	Water
	Sandy
	Reversal of Words, Letters, Numbers

Notes

Medical History

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	Self	Family
Heart Disease
Diabetes
High Blood Pressure
High Cholesterol
Ears, Nose, Throat
Lungs, Breathing
Skin
Glands
Muscle, Bones, Nerves
Neurological, Mental

	Self	Family
Learning
Glaucoma
Eye Disease
Eye Surgery
Dyslexia
Turned Eye
A "Lazy" Eye
Color Vision
Blindness
Eye Injury

Additional Notes

Tobacco	yes no	None One pack a day One pack a week Socially More than a pack a day Other
Drugs	yes no	None Marijuana Cocaine Meth Currently Clean Other
Alcohol	yes no	None Occasionally Beer one a day Other

General Health	Good Poor Moderate Other
Primary Physician	None Other

Results of Last Medical Visits

Medications

Allergies to Medicines	None Penicillin Sulphur Other
Other Allergies	None Spring Allergy Peanuts Other

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