Patient Form Complete and submit this form before your appointment. Basic InformationTo 'Submit' form, all required fields in this section must be filled out.Name* First Middle Last Sex* Male Female Date of Birth* MM slash DD slash YYYY Marital Status* SSN Last 4*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employment Statusfull timepart-timeself-employedunemployedstudent Occupation Allow Messaging Hone Text Email Home PhoneCell PhoneEmail Address Employer InfoEmployer Name Occupation Spouse/ Partner's name First Last Date of Birth MM slash DD slash YYYY Employer Occupation Other Contact InfoPerson responsible for charges Relationship to Patient PhoneEmergency contact Emergency contact relationship PhoneVisit InformationFirst Visit Yes No Last eye exam date MM slash DD slash YYYY Reason for current visit Referred by Last Medical exam date MM slash DD slash YYYY Doctor's Name Eye Health - Check all that apply Amblyopia Burning Eyes Drooping Eyelid Eye Turn Foreign Body Sensation Headaches Loss of Vision - Central Redness Blurred Vision - Far Cataracts Dry Eyes Floaters/Spots Glaucoma Itchy Feeling Loss of Vision - Side Retinal Detachment Blurred Vision - Near Double/Distorted Vision Eye Surgeries Fluctuating Vision Glare/Light Sensitivity Infection of eye/lid Mucus/Discharge Tearing/Watery Eyes General Health - Check all that apply Allergies/Hay Fever Cancer Chronic Cough Gastrointestinal Problems Kidney Disease Thyroid/Endocrine Disease Asthma/Respiratory Cardiovascular/High BP Diabetes Heart Attack/Strokes Psychiatric Depression Skin Disorders Blood Disorders Chronic Bronchitis Emphysema Headaches/Migraines Rheumatoid Arthritis Weight Loss/Gain Do you smoke tobacco products? Yes, I smoke everyday Yes, I smoke occasionally No, I'm a former smoker No, I've never been a smoker Do you drink alcohol? Yes No Family history - Blood Relativescheck all that applyCONDITION Blindness MOTHER FATHER SISTER/BROTHER GRANDPARENTS Glaucoma MOTHER FATHER SISTER/BROTHER GRANDPARENTS Crossed Eyes MOTHER FATHER SISTER/BROTHER GRANDPARENTS Eye Surgeries MOTHER FATHER SISTER/BROTHER GRANDPARENTS Macular Degeneration MOTHER FATHER SISTER/BROTHER GRANDPARENTS Retinal Detachment MOTHER FATHER SISTER/BROTHER GRANDPARENTS Thyroid Disease MOTHER FATHER SISTER/BROTHER GRANDPARENTS Lupus MOTHER FATHER SISTER/BROTHER GRANDPARENTS Kidney Disease MOTHER FATHER SISTER/BROTHER GRANDPARENTS High Blood Pressure MOTHER FATHER SISTER/BROTHER GRANDPARENTS Arthritis MOTHER FATHER SISTER/BROTHER GRANDPARENTS Cancer MOTHER FATHER SISTER/BROTHER GRANDPARENTS Diabetes MOTHER FATHER SISTER/BROTHER GRANDPARENTS Heart Disease MOTHER FATHER SISTER/BROTHER GRANDPARENTS Medications Enter all medications taken, and for which condition each is taken. For each medication beyond the first, please click the plus symbol and enter your information.MedicationCondition AllergiesEnter all medications or substances to which the patient is allergic Please answer the following questions Are you pregnant or nursing? Yes No Do you drive? Yes No Do you have trouble driving at night? Yes No Do you wear glasses? Yes No Do you wear contacts? Yes No Do you experience blur, headaches, or eyestrain with computer use? Yes No Are you interested in laser (refractive) surgery to correct your vision? Yes No Have you ever been exposed to or infected with - Hepatitis HIV Syphilis VISION Insurance InformationInsurance Company ID Number Patient's relationship to Policy Holder Self Spouse Child Policy Holder's Sex Male Female Name of the Policy Holder Policy Holder's Phone NumberPolicy Holder's Date Of Birth MM slash DD slash YYYY MAJOR MEDICAL Insurance Information Insurance Company ID Number Patient's relationship to Policy Holder Self Spouse Child Primary Policy Holder's Sex Male Female Name of the Policy Holder Policy Holder's Phone NumberPolicy Holder's Date Of Birth MM slash DD slash YYYY Additional CommentsIs there anything else we should know? Let us know below.