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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
		Misc/Guardian

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

How did you hear about our office?

Are any of your family members already patients at oak hill eye care? If yes, who?

Please list any hobbies:

Are you interested in contact lenses? no yes

Have you ever worn contact lenses? no yes

What type of contact lenses have you worn in the past? None Rigid Soft

Do you have back up glasses for your contact lenses? Yes No

What do you normally wear for vision correction?

Do you have a current pair of sunglasses? Yes No

Do you have a current pair of computer only or office only glasses? Yes No

Do you have problems with glare? Yes No

Are you interested in laser vision correction? Yes No

Please list any eye problems that you are CURRENTLY experiencing such as stinging, itching, floaters, etc.

Please list any eye conditions with which YOU have been diagnosed such as glaucoma, macular degeneration, retinal detachment, lazy eye, etc.

Please list/explain any previous significant eye injuries.

Please list/explain any previous eye surgeries.

Please list any medications, prescription and non-prescription, YOU are currently using for your EYES.

Who was your last eye doctor?

Who is your primary care physician:

Please list any medications YOU are currently taking, prescription or non-prescription. Include dosages if possible.

Please list any medical conditions with which YOU have been diagnosed such as high blood pressure, high cholesterol, diabetes, heart disease, arthritis, stroke, etc.

Do you currently use tobacco products? No Smoker Smokeless tobacco

Are you currently pregnant or nursing? No Pregnant Nursing

Please list any medical conditions with which any FAMILY MEMBERS have been diagnosed such as high blood pressure, high cholesterol, diabetes, heart disease, arthritis, stroke, etc. Please indicate which relative.

Please list any eye conditions with which any FAMILY MEMBERS have been diagnosed such as glaucoma, macular degeneration, retinal detachment, etc.

Please list any allergies to medications.

Any other relevant information?

Submit