Watters Vision Eye Care Patient Information

Demographics

Please Fill Out The Following:

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/Zip Code

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 Eye Doctor		Misc./Guardian

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	Zip Code

Home Phone:
Work Phone:

Medical History

Please Fill Out The Following Information. Thank You.

Weight Height ft. in	Race	Ethnicity

Preferred Language	Smoking Status	Alcohol Use

Are You Pregnant Or Nursing?	Due Date / DOB

How Did You Find Out About Our Office? Details / Other

Marital status	Employer / School	Occupation	Grade In School

What Are Your Hobbies?

Please List All Prescription Medications That You Are Taking

Please List All Over-the-Counter Medications That You Are Taking

Please List All Medications That You Are Allergic To. If None, Please Write None

Please List The Name, Address, and Phone Number Of Your Primary Physician

Please List Any Eye Conditions You Have, Or Have Had. (i.e. Lazy Eye, Retna Detachment, Cataract, Glaucoma, Or Other)

Please Check Any Conditions Below That Anyone In Your Family Has, Or Has Had

	Relationship To You (i.e. Uncle)
Glaucoma		Have You Had Eye Surgery?	If So, What Type
Macular Degeneration		Have You Had An Eye Injury?	If Yes, Please Describe
Retina Detachment		Do You Have Problems With Glare / Light Sensitivity?
Diabetes		Do You Currently Wear Contact Lenses?
High Blood Pressure		Have You Ever Worn Contact Lenses? If So, What Type?
Autoimmune Disease		Are You Interested In Contact Lenses?

NOTES

Please Check Mark Whether Or Not You Have Or Have Had The Following:

No Yes	No Yes	No Yes	No Yes	No Yes
Glaucoma	Spots / Floaters	Flashes	Double Vision	Stinging / Burning / Itching
Weight Loss	Weight Gain	Fatigue
Skin Rash	Growths	Acne	Rosacea
Headaches	Migraines	Seizures	MS
Dysthyroid	Diabetes
Allergies	Sinus Problems	Dry Mouth / Throat	Cough
Asthma	Bronchitis	Emphysema	COPD
Hypertension	High Cholesterol	Heart Surgery	Vascular Disease	Heart Disease
Ulcer	Reflux
Kidney Stones	Frequent Urination	Enlarged Prostate	Kidney Disease
Arthritis	Joint Pain	Head or Neck Injury
Anemia	Bleeding Problems
Seasonal Allergies	Allergy Shots
Depression	Anxiety	Insomnia

Please List Any Types Of Cancer You Have Or Have Had

Please List Any Medical Conditions You Have That Are Not Listed Above

If You Have Diabetes, How Many Years Since Your Diagnosis?	Last Blood Sugar	Date

Last A1C Date

Optomap

Optomap

As part of our complete eye examinations, our doctors want all their patients to have an Optomap laser image of the retina EVERY year. This is a laser generated image of your Retina, Macula, Optic Nerve and Blood Vessels of your Retina.

This laser scan assists the doctors with their diagnosis and care of serious eye diseases such as Macular Degeneration, Glaucoma, Retina Detachment, Diabetic Eye Disease, and Cancer of the inside of the eye. It allows the doctors to compare your Retina findings with prior years. They can zoom in on specific areas and apply filters to enhance different layers of the retina. This is a benefit for early detection of eye diseases.

Early detection is crucial to your eye health!

With the Optomap in some cases the doctor may feel comfortable not dilating your eyes at every examination.

The fee is only $35 dollars. It is usually not covered by insurance. This is a small cost for the benefit it provides in helping to maintain your eye health.

Yes, please include the Optomap to help Watters Vision Care provide the best care for my eyes

I decline the Optomap

Name (Or name of parent or guardian):

Submit Your Data Here

Please Click The Button Below To Complete Your Submission. Thank You.