Patient Information Form

Please complete and submit this form as soon as possible.

First Name	Last Name	Middle Initial	Date of Birth	Age

Street Address / PO Box	City	State	ZIP

Sex				Marital Status	E-Mail Address	Home Phone	Cell Phone
M		F

First Visit?				Reason for Current Visit	Last Eye Exam Date		Referred By
Yes		No

Employment Status	Employer	Emp. Phone	Occupation

Employer Street	Employer City	Emp. State	Emp. ZIP

Other Contact Information

Person responsible for charges (if not patient)	Relationship To Patient	Home Phone	Work Phone

Who should we contact in case of an emergency?	Relationship To Patient	Home Phone	Work Phone

Eye-Health - Patient ( check all that apply )

Amblyopia (Lazy Eye)	Eye Surgeries	Itchy Feeling
Blurred Vision - Far	Eye Turn	Infection of Eye / Lid
Blurred Vision - Near	Floaters / Spots	Loss of Vision - Central
Burning Eyes	Fluctuating Vision	Loss of Vision - Side
Cataracts	Foreign Body Sensation	Mucus / Discharge
Double / Distorted Vision	Glaucoma	Redness
Drooping Eyelid	Glare / Light Sensitivity	Retinal Detachment
Dry Eyes	Headaches	Tearing / Watery Eyes

General-Health - Patient ( check all that apply )

Allergies / Hay fever	Chronic Cough	Kidney Disease
Asthma / Respiratory	Diabetes	Psychiatric / Depression
Blood Disorders	Emphysema	Rheumatoid Arthritis
Cancer	Gastrointestinal Problems	Thyroid / Endocrine Disease
Cardiovascular / High B.P.	Heart Attack / Stroke	Skin Disorders
Chronic Bronchitis	Headaches / Migraines	Weight Loss / Gain

Family History - Blood Relatives ( check all that apply )

Amblyopia (Lazy Eye)	Color Blindness	High Cholesterol
Arthritis	Diabetes	Macular Degeneration
Blindness	Eye Turn	Retinal Detachment
Cancer	Glaucoma	Stroke / Heart Attack
Cataract(s)	High Blood Pressure	Thyroid Disease

Family Physician - Physician's Name	Physician's Phone	Last Medical Exam Date

Medications - Enter all medications taken by patient ... and for what condition each is taken.

	Medication	Condition		Medication	Condition
1.			2.
3.			4.
5.			6.
7.			8.

Enter the name of all medications (or substances) to which the patient is allergic.

Please Answer The Following Questions

Are you pregnant or nursing?

Yes

Do you have trouble driving at night?

Yes

Do you wear glasses?

Yes

Contacts?

Yes

If Contacts, Type

Do you experience blur, headaches or eyestrain with computer use?

Yes

Are you interested in laser (refractive) surgery to correct your vision?

Yes

I have Questions

Vision Insurance Information

Insurance Company

Primary Insured's Sex

Patient's Relationship to Insured

» Self

Spouse

Child

Other

Insured's ID #

Group #

Insured's Date of Birth

Insured's Name

Insured's Phone

Other Insurance Information