Date 

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Title

Mr. Mrs. Ms. Dr. Other

If other please specify

Last Name

First Name

Middle name

Street Address

City

State

[Select State] Non US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Non US

Zip code

Home Telephone

Mobile Telephone

Work Telephone

Birthday

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Age

Gender

Social Security Number

Occupation

Employer

Email Address

Vision Care Insurance

Primary Medical Insurance

Primary Care Physician

Who may we thank for  referring you to our practice?

What is the main reason for your visit?

Do you wear glasses?

-select- Yes No

Are you interested in glasses? 

-select- Yes No

Do you wear contact lenses?

-select- Yes No

Are you interested in contact lenses?

-select- Yes No

Do you have any questions about refractive surgery (ex: LASIK)?

-select- Yes No

Past, Family and/or Social History: Is there anything in your past history, family history or social history which would help us care for you?

Past History (illnesses, injuries, medications, treatments)

-select- yes no

If yes, please explain:  

Family History (diseases, hereditary risk factors, glaucoma)

-select- yes no

If yes, please explain:  

Social History (past and current activities)

Do you use any of the following products?                              

Tobacco

-select- yes no

Alcohol

-select- yes no

Recreational Drugs

-select- yes no

Review of Systems: Do you have a problem with...

Eyes

Allergic/Immunolgic

Hematologic/Lymphatic

Blindness

-select- yes no

HIV

-select- yes no

Anemia

-select- yes no

Loss of vision

-select- yes no

Hay fever

-select- yes no

Bleeding disorder

-select- yes no

Distorted vision

-select- yes no

Medicine Allergies

-select- yes no

Swelling

-select- yes no

Blurred vision

-select- yes no

Constitutional

Integumentary

Double vision

-select- yes no

Fever

-select- yes no

Skin

-select- yes no

Cataracts

-select- yes no

Weight loss

-select- yes no

Breast

-select- yes no

Crossed eyes

-select- yes no

Cardiovascular

Musculoskeletal

Flashes or floaters

-select- yes no

Heart pain

-select- yes no

Arthritis

-select- yes no

Dry eyes

-select- yes no

High blood pressure

-select- yes no

Rheumatoid arthritis

-select- yes no

Watery eyes

-select- yes no

Vascular disease

-select- yes no

Muscle pain

-select- yes no

Red eyes

-select- yes no

Ear, Nose, Mouth, Throat

Joint pain

-select- yes no

Mucous discharge

-select- yes no

Sinus problems

-select- yes no

Neurological

Burning or itching

-select- yes no

Chronic cough

-select- yes no

Headaches

-select- yes no

Sandy or gritty feeling

-select- yes no

Dry throat/mouth

-select- yes no

Migraines

-select- yes no

Eye pain or soreness

-select- yes no

Chronic ear infections

-select- yes no

Seizures

-select- yes no

Glare/light sensitivity

-select- yes no

Endocrine

Psychiatric

Chronic eye infections

-select- yes no

Diabetes

-select- yes no

Nervous disorder

-select- yes no

Tired eyes

-select- yes no

Thyroid disorder

-select- yes no

Depression

-select- yes no

Halos

-select- yes no

Other glands

-select- yes no

Compulsive behavior

-select- yes no

Vision therapy

-select- yes no

Gastrointestinal

Respiratory

Eye surgery

-select- yes no

Ulcers

-select- yes no

Asthma

-select- yes no

Retinal detachment

-select- yes no

Constipation

-select- yes no

Shortness of breath

-select- yes no

Glaucoma

-select- yes no

Genitourinary

Emphysema

-select- yes no

Eye injury

-select- yes no

Genitals/kidneys/bladder

-select- yes no

Lung cancer

-select- yes no

If you answered yes to any of the above, please explain and list any medications: