English Spanish French Japanese Dicline to Specify
American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Pacific Islander White Decline to specify
Decline to specify Hispanic or Latino Native Hawaiian or other Pacific Islander Not Hispanic or Latino
Divorced Legally Separated Married Hispanic Single Widowed Other
Employed Full-Time Employed Part-Time Not Employed On Active Military Duty Retired Self-Employed Student Full-Time Student Part-Time Other
Employment Status - Other
How were you referred to our office?
Friend or Family Family Doctor Ophthalmologist Insurance Company Newspaper Television Radio Received Mailing Internet Other Optometrist Other
Email Postal Telephone Eye History
Contact Lens History
Do you drink alcohol?
No Yes, 1 per week Yes, 1 per day Yes, 2 or 3 per day Yes, 4 or more per day
Do you smoke?
No Yes, 1/2 a pack per day Yes, 1 pack per day Yes, more than 1 pack per day
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens) Primary Insurance
Please bring all insurance cards with you to your appointment.
If you have any comments you would like to add, please enter them here.