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Patient Information Form
Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.
Office Location
Patient First Name
Patient Middle Name
Patient Last Name
Date of Birth
Drivers License Number
Issuing State
Expires On
Contact's Home Phone
Contact's Mobile Phone
Contact's Email
Patient Occupation
Patient Employer
Work Phone
Patient Social Security #
Primary Insured Social Security #
Is this your first visit to our office?
Yes No
If yes, please tell us who referred you:
Please tell us the reason(s) for your upcoming visit:   (Check all that apply)
Exam  Glasses  Contacts  Eye Infection or Injury
Laser Vision Consultation  Medical Problem
Other, please explain:
Are you planning to get new glasses on this visit?
Yes No If Necessary
If you participate in any sports list them here:
Insurance Information
Medical Insurance Company
Medical Policy #
Medical Group #
Medicare #
Vision Insurance Company
Vision Policy #
Vision Group #
Medical History
To help our office better serve your specific needs, please check all that apply.  Please leave boxes unchecked for a NO answer.
Eye History
  Headaches GlareLight Sensitivity  Tired Eyes
  Eye Infection Excess Tearing/Watering Redness
  Drooping Eyelid Sandy or Gritty Feeling Itching
  Crossed Eyes Blurred Vision Distance  Dryness 
  Floaters or Spots    Distorted Vision (halos) Burning
  Loss of Side Vision  Foreign Body Sensation Loss of Vision
  Macular Degeneration Retinal Detachment Glaucoma
  Color Blindness Blindness Diabetic Retinopathy
  Amblyopia(lazy eye)  Eye Pain or Soreness Fluctuating Vision
  Double Vision Blurred Vision Near Mucous Discharge
  Cataract(s) Other    
General Health Condition
 Please provide your family doctor's name, address and contact information:
  Kidney Fever Muscles, Bones, Joints
  Ears, Nose, Throat Allergic Respiratory (Asthma)
  Neurological Skin  Psychiatric
  Joint Pain Endocrine Cardiovascular Disease
  Bleeding Problems Anemia Heart Disease
  Diabetes Genitals/Kidney/Bladder Cancer
  Pregnant or Nursing Sinus Congestion Runny Nose
  Smoke Cigarettes Post-Nasal Drip Chronic Cough
  Consume Alcohol Lupus Stroke
  High Blood Pressure Other System Thyroid Disease
  Dry Throat/ Mouth Chronic Bronchitis Emphysema
  Rheumatoid Arthritis AIDS/HIV Blood/Lymph
  Gastrointestinal Weight Loss    
Family History
  Stroke Arthritis Macular Degeneration
  Amblyopia (Lazy Eye)  Cancer Retinal Detachment
  Glaucoma Lupus Crossed Eyes 
  High B.P. Diabetes Cataract(s)
  Color Blindness Other Blindness
  Thyroid Disease Kidney Disease Heart Disease
Currently taking medication(s) - prescription and/or over the counter
  select from list or type in here...    
1. I take 
2. I take 
3. I take 
4. I take 
5. I take 
 If you take additional medications, please list them here:
Drug Allergies
Do you have any drug allergies?
Yes No
 If yes, please list the medication(s):
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