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patient_info

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									                                                  Patient Information
Last_____________________________ First__________________________ M F DOB____/____/____
Address___________________________________ City___________________ State______ Zip___________
Home (_____)_________________ Work (_____)__________________ Cell (_____)__________________
Employer________________________________________ Occupation_______________________________
SS# (for billing and insurance purposes) _________________________ Referred By___________________________
                                                 In Case of Emergency
Last_____________________________ First__________________________ Relation____________________
Home (_____)_________________ Work (_____)__________________ Cell (_____)__________________
                                               Ocular and Medical History
Reason for visit_____________________________________________________________________________
Age of glasses_____ Age of contacts_____ Last eye exam____/____/____ from Dr. _____________________
Do you experience any of the following?
                  N    Y                         N    Y                        N   Y
Blurred vision   Headaches                 Eye injury/surgery   _______________________
Double vision   Light sensitivity   Dilation                    year? ________
Do you or any of your family have the following?
                 None Self Relative                                        None Self Relative
Diabetes           ___________________ Crossed eyes                ___________________
High BP            ___________________ Glaucoma                    ___________________
Heart disease      ___________________ Cataracts                   ___________________
Thyroid disease    ___________________ Mac. degen.                 ___________________
Cancer             ___________________ Retinal disease    ___________________
Blindness          ___________________ Other_________    ___________________
Are you pregnant and/or nursing? N Y Who is your primary care doctor? Dr. ___________________
Are you taking any medications (prescription/OTC)? N Y Please list ____________________________
__________________________________________________________________________________________________
Do you have any allergies, medication or other? N Y Please explain ____________________________
__________________________________________________________________________________________________
                                                 Social History
 I would prefer to discuss my social history information directly with the doctor.
Do you drink use tobacco products use illicit drugs? If yes, explain ____________________________
Please list your hobbies ____________________________________________________________________
Do you use the computer? N Y How many hrs/day? 1-2hrs 2-4hrs 4-6hrs 6-8hrs 8+hrs
Are you bothered by glare or reflection, particularly when driving at night? N Y
Do you have more than one pair of current prescription eyewear? N Y
Do you currently have sunglasses that protect you from UV rays? N Y
Are you interested in contacts or Lasik?

                                                  Review of Systems
Constitutional                 N Y        Vascular/Cardiovascular      N Y     Hematologic/Lymphatic           N Y
      Fever                                  Chest Pain                          Anemia                     
      Weight Loss/Gain                       Vascular Disease                    Bleeding/Bruising          
Integumentary (Skin)                           Cholesterol                   Gastrointestinal
      Rosacea                           Respiratory                                Diarrhea                     
      Acne                                    Asthma                             Constipation                 
Eyes                                            Chronic Bronchitis           Genito-urninary
      Eye Pain/Soreness                      Emphysema                           Genitals/Kidney/Bladder      
      Loss of Vision                    Musculoskeletal                      Ear, Nose, Throat
      Discharge                               Arthritis                          Sinus Congestion           
      Itching/Burning                         Muscle Pain                        Post-Nasal Drip            
      Flashes/Floaters                        Joint Pain                         Sore Throat                
      Prominent Eyes                    Neurological                               Tinnitus (Ringing)         
Endocrine                                       Migraines                    Allergic/Immonologic             
      Thyroid/Other Glands                    Seizures                     Psychiatric                      
Signature___________________________________________                  Date_________________________________

								
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