Patient Forms

Demographics

Patient Information

• Name Mr. Mrs. Ms. Dr. Rev. Title First Last MI Suffix Nickname
• Address Street Address 1 Street Address 2 City 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 State Zip
• Home Phone
• Work Phone:
• Other Phone
• Cell Phone:
• Email
• Preferred Contact Method Home Phone Work Phone Cell Phone Other Phone Text Message Email
• Birthday
• SSN
• Sex Male Female
• Employment Status Employed Full-Time Student Part-Time Student
• Occupation
• Employer / School Name
• Marital Status Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed
• Misc/Guardian

Billing Information

• Is The Billing Address the Same? Yes
• Name Mr. Mrs. Ms. Dr. Rev. Title First Last MI Suffix Nickname
• Address Street Address 1 Street Address 2 City 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 State Zip
• Home Phone
• Work Phone

Medical History

• How did you hear about our office?
• Are any of your family members already patients at FOCUS Vision and 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?

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