Date:

Patient Name:

First Last

DOB:

Address:

Street Address City State ZIP Code

Email:

Phone:

Cell Phone:

Date of Last Eye Exam:

Social Security Number:

Primary Physician:

Date of Last Medical Exam:

Occupation:

Hobbies:

Are you currently pregnant or nursing?

Yes
No
N/A

Glasses

Do you wear glasses?

Yes
No

Are they for Near Vision?

Yes
No

Are they for Distance Vision?

Yes
No

Any problems with Near Vision with our without glasses?

Yes
No

Any problems with Distance Vision with our without glasses?

Yes
No

Contact Lenses

Do You Wear Contacts?

Yes
No

What type of Lenses do you wear?

Soft
Disposable
Dailies
Extended Wear
Bifocal
Gas Permeable
Hard Lenses

Are you happy with your current lenses:

Yes
No

Wearing Schedule:

Daily
Overnight

Solution Used:

VISUAL CONCERNS:

HEADACHES:

Yes
No

How long have you had them?

PAIN IN EYE:

Yes
No

Please specify:

Right
Left
Both

Where is Pain Located:

How Long?

DOUBLE VISION:

Yes
No

SPOTS:

Yes
No

FLASHES:

Yes
No

DRY EYES:

Yes
No

BURNING EYES:

Yes
No

OTHER:

Yes
No

If other, please specify:

PRIOR DIAGNOSES OR PROBLEMS:

Personal Medical History (Review of Systems):

Please check if any of the following applies to you past or present and list all medications below.
If you have none of these conditions, please check NONE.

Cardiovascular:

None
High Blood Pressure
High Cholesterol
Heart Disease
Vascular Disease
Stroke
Other

If other, please specify:

Endocrine:

None
Type 2 Diabetes
Type 1 Diabetes
Thyroid Problem
Hormonal Dysfunction
Other

If other, please specify:

Constitutional:

None
Cancer
Trauma/Large Volume Blood Loss
Developmental Disability
Other

If other, please specify:

If cancer, please specify the type:

Respiratory:

None
Asthma
Bronchitis
Emphysemia
COPD
Other

If other, please specify:

Neurological:

None
Multiple Sclerosis
Epilepsy/Seizure Disorder
Cerebral Palsy
Tumor
Migraines/Headache Disorder
Other

If other, please specify:

Musculoskeletal:

None
Arthritis
Fibromyalgia
Muscular Dystrophy
Anklosing Spondylitis
Other

If other, please specify:

Immunological:

None
AIDS or HIV
Lupus
Neurological
Other

If other, please specify:

Heomatological:

None
Anemia
Leukemia
Other

If other, please specify:

Gastrointestinal:

None
Chrone's
Colitis
Other

If other, please specify:

Ear/Nose/Throat:

None
Hearing Loss
Upper Respiratory Infection
Other

If other, please specify:

Dermatologic:

None
Eczema
Rosacea
Psoriasis
Skin Cancer
Other

If other, please specify:

Allergies:

None

Please List Allergies:

Drug/Medication:	Environmental:	Other:

Alcohol Use

Yes
No

Amount:

Tobacco Use

Current
Past
Never

Amount:

Number of Years:

Please list any medications that you are taking:

(Including vitamin, herbs, supplements and over the counter)

FAMILY HISTORY:

Has anyone in your immediate family (grandparents, parents, siblings, children, living or deceased) been diagnosed with:

Lupus:

Yes
No

Relationship:

High Blood Pressure:

Yes
No

Relationship:

Diabetes:

Yes
No

Relationship:

Heart Disease:

Yes
No

Relationship:

Thyroid Disease:

Yes
No

Relationship:

Cancer:

Yes
No

Relationship:

If cancer, please specify the type:

Blindness:

Yes
No

Relationship:

Cataracts:

Yes
No

Relationship:

Glaucoma:

Yes
No

Relationship:

Crossed Eyes:

Yes
No

Relationship:

Macular Degeneration:

Yes
No

Relationship:

Retinal Detachment:

Yes
No

Relationship:

Other:

Yes
No

Relationship:

If other, please specify:

Patient Signature

Date

New Patient Form

Glasses

Contact Lenses

VISUAL CONCERNS:

Personal Medical History (Review of Systems):

FAMILY HISTORY: