Crystal PM Patient Forms

Demographics

Patient Information

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
Misc/Guardian

How did you find and/or hear about us?

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Medical History

Eye History

Do you currently have any of these symptoms?:
Do you take any eye medications?:

Last Eye Exam:

By Doctor:

Type of contacts worn in the past:

Family Eye History

Macular Degen:		Glaucoma:
Retinal Detach:		Cataracts:
Lazy/Crossed Eye:

Medical History

Medications:	Allergies (including drug allergies):

Please describe any injuries or surgeries you have had:

Vitamins:

Pregnant Or Nursing:

Do you or anyone in your family have any of these medical conditions?

Diabetes:		Years Ago Diagnosed (if self):
Hypertension:
High Cholesterol:
Thyroid Condition:
Heart Condition:
Cancer:

Review of Systems

General:		Ear/Nose/Throat:
Skin:		Cardiovascular:
Respiratory:		Musculoskeletal:
Psychiatric:		Gastrointestinal:
Endocrine:		Blood/Lymph:
Neurological:		Genitourinary:
Immune:

Social History

Hobbies:

Occupation:

Employer:

STD's:

Smoking Status:

Alcohol Use:

Illegal Drug Use:

Race:

Medical Insurance

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:
SSN:
Employer/School:

Vision Insurance