Download PDF of our Patient History form

Welcome to Racine Optical Co.
Date ..................................................
Employer/School ................................................................................
Last ...........................................First ............................. MI .............. Occupation .........................................................................................
Address ................................................................................................ Your DOB ...................................................Age ................................
City ...........................................State ............................ ZIP .............. Insurance Subscriber’s Name & DOB ..............................................
Best Phone Number .......................................................................... .............................................................................................................
SSN....................................................................................................... *PLEASE present your MEDICAL & VISION INSURANCE cards for
Email Address .................................................................................... our reconds.*
Main purpose of your visit today? Check One.
☐ Eye Glasses
☐ Contacts
☐ Vision & Eye Health
Are you having problems with your current contacts or glasses? ......................................................................................................................
How did you hear about us? ☐ Radio ☐ Ad ☐ TV ☐ Friend (Please name)...........................................................................................
Medical History
Do you or any of your family have the following conditions?
Name of family physician .................................................................
Condition
You Family Relation
Blindness
☐☐
....................................... Date of last physical exam..................................................................
Cataracts
☐☐
....................................... Current medications (Rx or over the counter). List name of medicaCorneal Problems
☐
☐
....................................... tion, including eye drops, vitamins and birth control.
Glaucoma
☐☐
....................................... ...........................................................................................................
Lazy Eye
☐
☐
....................................... ...........................................................................................................
Retinal problems
☐
☐
....................................... ...........................................................................................................
Diabetes
☐☐
....................................... Do you have any medication allergies? ☐ Yes ☐ No
Heart Disease
☐
☐
....................................... If yes, please list ................................................................................
Macular Degeneration ☐
☐
....................................... ...........................................................................................................
Have you ever been diagnosed or treated for any of the following?
☐ Corneal Abrasion
☐Iritis/Uveitis
☐Eye Injury
☐Lasik / RK
☐Eye Infection
☐Retinal Detachment
☐Other Eye Disorders (List below)
...........................................................................................................
☐Allergies
☐High Blood Pressure
☐ Asthma
☐High Cholesterol
☐ Arthritis
☐Thyroid Problems
☐Cancer
☐Other Medical Issues (List below)
..............................................................................................................
Tell us about yourself...
Do you currently wear contact lenses?. ☐ Yes ☐ No
Check one.
☐ Dailies
☐ 2-Week
☐ Monthlies
What solutions used? .........................................................................
If you wear contact lenses, are you satisfied with your vision
and comfort?
☐ Yes ☐ No
Would you prefer contact lenses to change the color of your
eyes?
☐ Yes ☐ No
Do you have an interest in a “test drive” of the latest contact
lens designs?
☐ Yes ☐ No
Patient Eye History
Date of last eye exam ........................................................................
Do you experience the following? (Check box if your answer is yes)
☐ Blurry Vision
☐Grittiness
☐Burning Eyes
☐Itchy Eyes
☐ Tearing
☐Occasional Dryness
☐ Headaches
☐Sunlight Sensitivity
☐Double Vision
☐Crossed Eye / Eye Turn
☐Flashes of Light
☐Trouble Seeing at Night
☐ Floaters
☐Uncomfortable Glasses
Do you...(Check box if your answer is yes)
☐Work at a computer?
☐Think you’d benefit from thinner, lighter lenses?
☐Spend time outdoors?
☐Have prescription sunglasses?
☐Prefer not to wear glasses at times?
☐Want information on Laser Vision Correction surgery?
☐Have children or family in need of eye care?
☐If you wear bifocals, do the lines or head tilting other you?
Payment Policy:.
Eyewear and Contact Lenses — A 50% down-payment is required on all purchases with remaining balance to be paid at dispensing. Every
pair of eyewear is custom made for your eyes, so returns are subject to a 30% restocking fee.
Professional Services — Payment in full is expected at the time of service. If you have vision and/or health insurance, we will submit a claim
for you. The balance on your account will remain your responsibility.
I agree and understand that regardless of my insurance status, I am ultimately responsible for the balance on my account for any service rendered. I authorize the release of any information necessary to process my insurance claim.
Signature ....................................................................................................................................... Date ........................................................................................
Would you like a copy of Racine Optical’s Notice of Privacy Practices for your records? ☐ Yes
☐ No