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Mr. Miss Mrs. Ms.
Name ________________________________________________________________________________________
First MI Last Nickname
Address: _______________________________________________________________________________________
City:__________________________________State ____________________________ Zip ______________
Date of Birth: ____________________________ SS # (last 4 digits)_______________
Phone: Home____________________________ Cell: _____________________________Text OK? __________
Circle One: Single Married Widow Divorce
Email:____________________________________________________
Occupation: ________________________________Employer: _______________________________________
Spouse Name: ________________________ Parent(s) Name if under 18 _________________________________
-Are you Diabetic? Yes No
-Are you interested in wearing Contact Lenses: Yes No
-Are you interested in Lasik?: Yes No
Are you on Hospice Care? Yes No
-INSURANCE INFORMATION:
-Vision Insurance Co: ____________________________________ ID # _______________________________
Name of Insured:_______________________________Date of Birth______________
SS# _____________________________________________________
-Medical Insurance Co: __________________________________ ID # _______________________________
Name of Insured: ______________________________ Date of Birth _____________
SS#______________________________________________________
-Today’s Visit: Please Mark One:
____________ I prefer dilation today (included in the exam)
____________ I prefer Optomap Digital Retinal Imaging (Additional Charge-see info at front desk)
-I authorize the release of all medical or other information needed to provide a complete visual
Examination and/or process the insurance claim.
-I understand that I am financially responsible for all charges which may or may not be paid by the
Insurance company.
***PAYMENT or Co-Pay is DUE AT THE TIME SERVICES ARE RENDERED***
Signed_______________________________________________ Date _______________________________
--PATIENT HISTORY--
Name:__________________________________________________________ DOB: _____ / _____ / _____
(FIRST) (MI) (LAST)
Primary Care Physician: _____________________________________________________________________________________
Medications: (If you have a list, please provide to check-in desk)___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________
List Current Medical Illnesses (i.e. hypertension, diabetes, depression, etc.) ________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
Eye Medications: _______________________________________________________________________________________________________________________________________________________________________________
Are you on any blood thinners such as aspirin? YES / NO Please list: _______________________________________________________________________________________________________________________________________________________________________________
Drug Allergies (if yes, please list):
_______________________________________________________________________________
Prior Surgeries, include dates (especially those pertaining to EYES, CARDIOVASCULAR or NERVOUS SYSTEM):
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY
Pregnant: YES / NO / Not applicable
Alcohol intake: YES / NO Daily / Frequently / Occasionally / Rarely / Never
Tobacco / Vapor Use: Current / Former / Never Cigars / Cigarettes / Chewing tobacco / Vape
FAMILY HISTORY
For any YES answers please provide the relationship of the family member
Glaucoma YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Cataracts YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Retinal Detachment YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Macular Degeneration YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Diabetes YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
High Blood Pressure YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Cancer YES / NO mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather