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Patient Information Form
Patient Name_________________________ Gender: ______ Date of Birth_______________
Mailing Address_______________________________________________________________
City__________________________ State_____________ Zip Code______________________
Home Phone___________________ Cell Phone________________ other_________________
Email________________________________________________________________________
Insurance
Medical Insurance__________________________________________________
Vision Insurance____________________________________________________
Policy Holders Name________________________________________________
Policy Holders DOB_______________
Policy Holders Last 4 of SSN and work ID # if applicable____________________
Patient Visual Information
Date of Last Eye Exam______________ Dr. Name and location__________________________
Do you wear contacts? ___________ Any interest in contacts today? ______________________





I am happy with comfort
I am happy with the vision
I am looking for multifocal contacts
I am looking to have colored contacts
I am looking to change current wear schedule of the contacts (daily, 2 week, monthly)
Do you wear glasses? __________ What type of lenses? _____________________________
Please circle if you currently have or have experienced:
Glaucoma
Cataracts
Iritis Uveitis
Macular Degeneration
Chronic Conjunctivitis
Turned Eye(strabismus)
Retinal Detachment Eye Patching
Chronic Dry Eye
Keratoconus
Blepharitis
LASIK
Eye Injury(s)
Please use this space and add additional comments concerns and surgical date that you have
had:
________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Patient Medical Information
Please circle any that you have had or are currently experiencing
Cardiovascular
Endocrine
Gastrointestinal
High Blood Pressure
Stroke
Heart Disease
Vascular Disease
Cholesterol
Angina
Congestive Heart Failure
Crohn’s
Diabetes
Thyroid Dysfunction
Gout
Renal Disease
Acid Reflux
Ulcer
Colitis
Celiac Disease
Hepatitis
Diverticulosis
OTHER _________________________________________________________________
Genitourinary
Ear, Nose, Mouth, Throat
Hematologic/ Lymphatic
Kidney Disease
Cancer
Sexually transmitted Disease
Herpes
Chronic Cough
Sinusitis
Meniere Syndrome
Dry Mouth
Anemia
Leukemia
Hodgkin’s Disease
Sickle Cell Disease
OTHER______________________________________________________________________
Immunologic
Integumentary
Musculoskeletal
Sjogren’s Syndrome
Herpes
Lyme Disease
HIV
AIDS
Eczema
Rosacea
Psoriasis
Lupus
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Arthritis
Scoliosis
OTHER________________________________________________________________________
Neurological
Psychiatric
Respiratory
Bell’s Palsy
Horner’s Syndrome
Headaches
Nystagmus
Parkinson
Multiple Sclerosis
Vertigo
Depression
Anxiety
Alzheimer’s
Attention Disorder
PTSD
Autism
Dementia
Asperger’s
Asthma
COPD
Bronchitis
Emphysema
Pneumonia
Cystic Fibrosis
Sarcoidosis
Tuberculosis
OTHER________________________________________________________________________
Woman only: Are you currently pregnant? __________________
Currently Breastfeeding: _______________
Anything that you feel should be known or any accommodations that would be helpful to
make your eye exam more comfortable for you:
___________________________________________________________________________
____________________________________________________________________________
Please list any and all medications, vitamins, and supplements you are currently taking
___________________________
_________________________
___________________________
_________________________
___________________________
_________________________
___________________________
_________________________
___________________________
__________________________
___________________________
__________________________
Please indicate any immediate family members with any of the following disorders
and their relation to you:
Cataract: _________________
Glaucoma: _______________
Macular Degeneration: ______________
Other eye disorders: _______________
Diabetes: _______________
High Blood Pressure: _______________
High Cholesterol: _______________
Cancer: _______________
Thyroid Disorder: _______________
Other health issues: _______________