Welcome Back

WELCOME BACK TO OUR OFFICE fields marked with an "*" are required Name * Today's Date mm/dd/yyyy Spouse or Parent * Mailing Address * City * State/Province * Zip/Postal Code * Date of Birth mm/dd/yyyy * Age * Sex: Male Female Home Phone xxx-xxx-xxxx * Work Phone xxx-xxx-xxxx * Social Security # xxx-xx-xxxx * Email Address (for patient communication only) MEDICAL HISTORY Allergies Arthritis Heart Disease Asthma Cancer Skin Disorder Diabetes Cataracts High Blood Pressure Eye Injury Eye Surgery Glaucoma Nerves Kidney Problems Other CURRENT MEDICATIONS (Rx or over the counter) Medication Name Antihistamines Blood Pressure Pills Diuretic (water pill) Oral Contraceptives Sleeping Tablets Eye Drops Others Allergies to Medications Date of Last Eye Exam xx/xx/xxxx Name of Last Eye Doctor Date of Last Physical Exam xx/xx/xxxx Name of Physician FAMILY MEDICAL HISTORY Relationship to you Blindness Glaucoma Diabetes High Cholesteral Other SOCIAL HISTORY This information is kept strictly confidential. However, you may discuss this portion with the doctor if you prefer. This information is important for medical purposes as well as compliance with insurance directives. Would you prefer to discuss your Social History information with your doctor? YesNo Do you use tobacco products? YES NO Do you drink alcohol? YESNO Employer (or School) Occupation (or Grade) What is the major purpose of this visit? Any problems with your present contact lenses or glasses? Vision Insurance Medicare Medicaid VSP Blue Cross Flex Plan Other How will you settle your account? Check Financing Credit Card Insurance Cash Do you experience........(check those that apply) Burning Uncomfortable Glasses Itchiness Sudden loss of vision Nausea Sensitivity to light Watery Eyes Fainting or dizziness Double Vision Blurry distance vision Flashes of Light Blurry near vision Glare or Reflection Gritty feeling in eyes Soreness Objects floating in vision Eye Strain Trouble seeing at night Headaches Dryness Redness Other VISUAL NEEDS Do You........(check the box if your answer is yes) Work on a computer for long periods of time? Have only one pair of glasses? Want information on thinner, lighter lenses? Wear bifocals? Want information on "no line" bifocals? Prefer not to wear your glasses at times? Spend a lot of time outdoors? Ever find a need for prescription sunglasses? Have problems with glare or reflections (ex: night driving)? Do work requiring safety glasses? Participate in sports? Which? Want more information about corrective vision surgery? Wear or ever tried wearing contacts? What kind? When you are finished, please click on the Print button only once. If you would like to clear the form and start over, click on the Reset button. Print Page

Home | Meet our Staff | Hours & Location | News | About our Practice | Our Services | Eye Health Vision Care Products | Vision Benefits Plan | Just For Kids | Our Office Forms © 2005 Advanced Eyecare Associates.