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Download Patient Info Form - Gramercy Park Optical
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Return Visits Reason for visit: ____________________________________________ Last eye exam: ______________ By whom? _____________________ Who referred you to our office?________________________________ Do you wear glasses? ………………………………….. Yes No Do you wear contact lenses …………………………...... Yes No If yes, what type?___________________________________________ How much time do you spend on a computer? ____________________ Occupation: _______________________________________________ Have you ever had an eye infection, injury or surgery?.. Yes No If yes, please specify ________________________________________ Do you have a history of glaucoma, cataracts, lazy eye or any other eye problems? …………………………………………….… Yes No If so, please specify_________________________________________ Do any of your family members have glaucoma, cataracts, blindness or any other eye problems? ………………………..………. Yes No If so, please specify ________________________________________ Do you have any medical problems, such as high blood pressure, diabetes, cardiovascular, thyroid, etc.? ………………….….…….. Yes No If so, please list_______________________________________________ Do you take medications? …………………………….... Yes No If so, please list______________________________________________ Are you allergic to any medications: …….......…………. Yes No If so, please list______________________________________________ Do you have frequent or severe headaches? ……….….. Do you have pain in or around your eyes? ……….……. Do you ever have double vision? ……………….……... Do you ever see flashes of lights or lightning streaks?.... Do you ever see floaters (black spots)? ………………... Do you ever see halos or rings around lights? ……….... Yes Yes Yes Yes Yes Yes No No No No No No Do you have eye care insurance? …………………..….. Yes No If yes, please name ____________________________________________ Patient’s date of birth __________________________________________ Patient SS# __________________________________________________ Insured SS# _________________________________________________ Thank you. We will be with you as soon as possible.
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