PATIENT INFORMATION
Today's Date
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Month
-
Day
Year
Date
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Patient Name
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First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
May we text you reminders and order status update?
Yes
No
May we leave a voice message if needed?
Yes
No
E-mail Address
example@example.com
May we e-mail reminders and order status updates?
Yes
No
Preferred Method of Contact
Please Select
Home Phone
Work Phone
Cell Phone
Text
E-mail
Gender
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Divorced
Separated
Widowed
Other
Social Security Number
Employer
Occupation
Employment Status
Please Select
Full Time
Part Time
Student
Retired
Ethnicity
Please Select
Hispanic/Latino
Pacific Islander
Not Hispanic or Latino
Race
Preferred Language
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PERSON RESPONSIBLE FOR PATIENT'S PAYMENT
Who is responsible for this account?
Self
Spouse
Parent/Guardian
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
Social Security Number
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Gender
Please Select
Male
Female
Relationship to Patient
Please Select
Self
Spouse
Parent/Guardian
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VISION PLAN
Vision Plan Name
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FRONT OF INSURANCE CARD
BACK OF INSURANCE CARD
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Who is responsible for this account?
Self
Spouse
Parent/Guardian
Primary Insured's Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
Insured's Home Phone
Please enter a valid phone number.
Insured's Cell Phone
Please enter a valid phone number.
Insured's Work Phone
Please enter a valid phone number.
Employer
Social Security Number
Gender
Please Select
Male
Female
Member ID Number
Group Number
Relationship to Patient
Please Select
Self
Spouse
Parent/Guardian
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MEDICAL PLAN
Medical Plan Name
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FRONT OF INSURANCE CARD
BACK OF INSURANCE CARD
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Who is responsible for this account?
Self
Spouse
Parent/Guardian
Primary Insured's Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
Insured's Home Phone
Please enter a valid phone number.
Insured's Cell Phone
Please enter a valid phone number.
Insured's Work Phone
Please enter a valid phone number.
Employer
Social Security Number
Gender
Please Select
Male
Female
Member ID Number
Group Number
Relationship to Patient
Please Select
Self
Spouse
Parent/Guardian
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Primary Care Doctor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Primary Pharmacy Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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HEALTH INFORMATION
Reason For Today's Visit (Check All That Apply)
Blurred Vision
Eye Irritation/Discomfort
Other symptoms related to today's visit
Blurred Vision
Distance
Intermediate
Near
Do you wear glasses?
Yes
No, I have never worn glasses in the past
Not currently, but I have worn glasses in the past
Distance
Near
Computer
Full Time
Part Time
Do you wear contact lenses?
Yes
No, I have never worn contacts
Not currently, but I have worn contacts in the past
Date/Provider Last Eye Exam (Month/Year)
Brand/powers
Do you intentionally sleep in them?
Yes
No
Nights/Week
Are interested in wearing contact lenses?
Yes
No
OCULAR HISTORY
Self
Please check if you have or have had any of the following
Cataracts
Glaucoma
Retinal Hole/Tear
Retina Detached
Dry Eye Syndrome
Strabismus
Amblyopia
Floaters
Flashes of Light
Other (including surgeries)
Family
Please check if anyone in your family have or have had any of the following
Cataracts
Glaucoma
Retinal Hole/Tear
Retina Detached
Dry Eye Syndrome
Strabismus
Amblyopia
Floaters
Flashes of Light
Other (including surgeries)
Please list family relation
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MEDICAL HISTORY
Date of last physical (Month/Year)
Please list any other allergies you have, leave blank if you don't have any allergies
Please list any medications you are currently taking, leave blank if you don't have any medications
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REVIEW OF SYSTEMS
Please check if you have or have had any of the following conditions
CARDIOVASCULAR
Cardiovascular Disease
Elevated Cholesterol
Hypertension
Other
CONSTITUTIONAL
Fatigue (Chronic)
Other
ENDOCRINE
Diabetes Mellitus Type I
Diabetes Mellitus Type II
Hyperthyroidism
Other
GASTROINTESTINAL
Acid Reflux
Cancer (Colon)
Other
GENITOURINARY
Pregnant/Nursing
Prostate Disorder
Other
EAR, NOSE, THROAT
Dry Mouth
Hearing Loss
Sinusitis
Other
HEMATOLOGIC/LYMPHATIC
Anemia
Breast Carcinoma
Leukemia
Other
IMMUNOLOGIC
Herpes Simplex (Cold Sore)
Sarcoidosis
Sjogren's Syndrome
Other
INTEGUMENTARY
Rosacea
Psoriasis
Scleroderma
Other
MUSCOSKELETAL
Arthritis (Osteo)
Arthritis (Rheumatoid )
Myasthenia Gravis
Other
NEUROLOGICAL
Brain Tumor
Headache (Migraine)
Multiple Sclerosis
Other
PSYCHIATRIC
ADD (Attention Deficit Disorder)
Anxiety
Depression
Other
RESPIRATORY
Asthma
Emphysema
Lung Cancer
Other
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FAMILY HISTORY
Please check if any of your family have or have had any of the following conditions
CARDIOVASCULAR
Cardiovascular Disease
Elevated Cholesterol
Hypertension
Other
Please list family relation
CONSTITUTIONAL
Fatigue (Chronic)
Other
Please list family relation
ENDOCRINE
Diabetes Mellitus Type I
Diabetes Mellitus Type II
Hyperthyroidism
Other
Please list family relation
GASTROINTESTINAL
Acid Reflux
Cancer (Colon)
Other
Please list family relation
GENITOURINARY
Pregnant/Nursing
Prostate Disorder
Other
Please list family relation
EAR, NOSE, THROAT
Dry Mouth
Hearing Loss
Sinusitis
Other
Please list family relation
HEMATOLOGIC/LYMPHATIC
Anemia
Breast Carcinoma
Leukemia
Other
Please list family relation
IMMUNOLOGIC
Herpes Simplex (Cold Sore)
Sarcoidosis
Sjogren's Syndrome
Other
Please list family relation
INTEGUMENTARY
Rosacea
Psoriasis
Scleroderma
Other
Please list family relation
MUSCOSKELETAL
Arthritis (Osteo)
Arthritis (Rheumatoid )
Myasthenia Gravis
Other
Please list family relation
NEUROLOGICAL
Brain Tumor
Headache (Migraine)
Multiple Sclerosis
Other
Please list family relation
PSYCHIATRIC
ADD (Attention Deficit Disorder)
Anxiety
Depression
Other
Please list family relation
RESPIRATORY
Asthma
Emphysema
Lung Cancer
Other
Please list family relation
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SOCIAL HISTORY
Do you smoke?
Yes
No
Formerly Quit
How many packs/week and for how many years?
When did you quit smoking?
Do you drink alcohol?
Yes
No
Formerly Quit
How many drinks/week and for how many years?
When did you quit drinking?
Do you use recreational drugs?
Yes
No
Type and Frequency
Have you ever had a blood transfusion?
Yes
No
Do you have any sexually transmitted diseases?
Yes
No
HIV
Signature of Patient or Personal Representative
*
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Date
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Month
-
Day
Year
Date
Name of Patient or Personal Representative
First Name
Last Name
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