Patient Information

Patient Information

Gender:
Marital Status:

Spouse/Parental Contact (If college student please include)

Insurance

Do you have insurance?

Referral

How did you decide to come to our practice?
Have other family members been seen in this office by our doctors?:

Medical History

Are you under care of a physician now?
Are you pregnant?
Are you nursing?

Vision History

Glasses
Do your current glasses have bifocals?
Do you always wear your glasses?
Do you have prescription sunglasses?
Contacts
Are you interested in contact lens?
If you wear contacts, are you interested in hearing about new lens technology?
Do you currently or have ever had any problems in the following areas?
Blurred vision
Burning
Night driving
Distorted vision/halos
Double vision
Dryness
Excess tearing/watering
Eye pain/soreness
Chronic eye/lid infection
Flashes/floaters in vision
Foreign body sensation
Glare/light sensitivity
Head/eye injuries
Illness that affected eyes
Itching
Loss of side vision
Mucus discharge
Redness
Sandy/gritty feeling
Styes/chalazion
Tired eyes
Do you currently suffer from headaches?:
Headache severity:
Time of day headaches occur?
How frequent are the headaches?
Where are the headaches generally located?
Do the headaches include visual disturbance?

Review of Systems

Do you currently or have ever had any problems in the following areas?
Cardiovascular
Chest Pain
High Blood Pressure
Low Blood Pressure
Rapid Heartbeat
Irregular Heartbeat
Swollen Ankles
Vascular Disease
High Cholesterol
Psychiatric
Depression
Insomnia
ADD/ADHD
Anxiety
Alzheimers
Neurological
Dizzy Spells
Head Injury
Headaches
Migraines
Seizures
Stroke
Epilepsy
Parkinson's Disease
Bones/Joints/Muscles
Joint Pain
Muscle Pain
Arthritis
Rheumatoid Arthritis
Gastrointestinal
Crohn's Disease
Heartburn
Ulcer
Acid Reflex Syndrome
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Persistent Cough
Pneumonia
Tuberculosis/TB
Endocrine
Diabetes/Blood Sugar
Treatment:
Thyroid/Other Gland
Social History
Do you use tobacco products?
Do you use alcohol?
Do you use illegal drugs?
Ears, Nose, Mouth, Throat
Allergies/HayFever
Chronic Cough
Dry Throat/Mouth
Sinus Congestion
Hearing Loss
Lymphatic/Hematologic
Anemia
Blood Clots
Bleeding Problems
Cancer
Integumentary (skin)
Acne
Dry Skin
Psoriasis
Rosacea
Lupus
Genitourinary
Bladder Infection
Kidney Stones
Menopause
Prostate Disorder
Please check if you have ever been exposed to or infected with:

Allergies

Food Allergies
Drug Allergies
Environmental Allergies

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
ADD/ADHD
Arthritis
Blindness
Allergies
Cataracts
Cancer
Strabismus
Diabetes
Amblyopia
Heart Disease
Dyslexia
Blood Pressure
Glaucoma
Kidney Disease
Macular Degeneration
Lupus
Retinal Detachment
Thyroid

Vision Therapy

Have any of the following traits been noted? (Check the box if applies)
PLEASE NOTE: Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, you will need to pay our office at the time of service and submit your receipt for reimbursement from your insurance company. If your insurance does not pay as expected, you are ultimately responsible for all charges, including copays and deductibles. We cannot be responsible if you are not eligible for benefits. We will be happy to assist you with your claims. Please give any forms to the receptionist.