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Vision Source Trophy Club
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2017-07-06T01:14:22+00:00
Vision Source Trophy Club
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Title
First
MI
Last
Suffix
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Cell Phone
*
Home Phone
Business Phone
Email
*
Social Security Number
Birthdate
*
MM slash DD slash YYYY
Sex
Male
Female
Marital Status
*
Single
Married
Divorced
Widow/Widower
Occupation
Employment Status
Employed
Full-Time Student
Part-time Student
Employer
Primary Doctor
Dr Lam, Kelvin
No Doctor Assigned
Misc / Guardian
Insurance
Insurance Company
*
Insurance ID
*
Insurance Policy Group
Primary on Account
Not Primary
Name of Primary on Account
First
Last
Relationship to Insured
Spouse
Child
Other
Sex
Male
Female
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Date of Birth
MM slash DD slash YYYY
Employer / School
Medical History
Primary Care Physician
Don't Have One
Don't Remember
None
Other
Last Visit
1 week
1 month
3 months
6 months
1 year
Other
Reason for Visit
Annual
Checkup
Other
Injuries, Surgeries, Hospitalizations
None
Other
Recent Tetanus Shot
Yes
No
Other
Review of Systems
*If other, please describe in Notes below
General
None
Negative
Other
Ear, Nose, Throat
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
Cardiovascular
None
Vascular Disease
HBP
Heart Surgery
Respiratory
None
Asthma
Bronchitis
Emphysema
COPD
Other
Genital, Kidney, Bladder
None
Painful Urination
Frequent Urination
Impotence
Yellow Jaundice
Other
Muscles, Bones, Joints
None
Joint Pain
Stiffness
Swelling
Cramps
Arthritis
Other
Skin
None
Pimples, Warts
Growths
Rash
Other
Neurological
None
Numbness, Paralysis
Headache
Seizures
Migraines
Other
Psychiatric
None
Anxiety
Depression
Insomnia
Other
Endorcrine
None
Diabetes
Hypothyroid
Hyperthyroid
Other
Blood / Lymph
None
Bleeding
Cholestrolemia
Anemia
Other
Allergic / Immunologic
None
Sneezing
Swelling
Redness
Itching
Hives
Lupus
Other
Gastrointestinal
None
Diarrhea
Constipation
Ulcer
Acid Refllux
Other
Notes:
Social History
Occupation
Engineer
Firefighter
Nurse
Police Officer
Salesman
Student
Teacher
Other
Hobbies
Art
Astronomy
Baseball
Basketball
Boating
Cooking
Crafts
Dancing
Diving
Fishing
Football
Gardening
Golf
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Roller Blading
Running
Sewing
Skiing
Soccer
Softball
Swimming
Tennis
Video Games
Woodworking
Other
Smoking Status
Never Smoker (<100 cigs equiv)
Former Smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs a day)
Heavy smoker (>10 cigs a day)
Smoker (current status unknown)
Current every-day smoker
Unknown if ever smoked
Other
Type
Chewing Tobacco
Cigarettes
None
Other
How Long?
Alcohol
No
Occasionally
Socially
Yes
Other
Type
Beer
Hard Liquor
Wine
Other
None
How Long?
Illegal Drugs
No
Yes
Other
Type?
How Long?
STDs
Gonorrhea
Hepatits
HIV
None
Syphilis
TB
Other
Review of Ocular System
Patient Eye Health
*
Amblyopia (lazy eye)
Burning Eyes
Cataracts
Eye Injuries
Eye Surgery
Flashes of Light
Floaters
Glaucoma
Itching
None
Retinal Disorders
Strabismus
Other
Retinal Detachment
Tearing/Watery Eyes
None of the Above
Eye Meds
Alphagan
Alrex
Blink
Cromolyn NA 4%
Elestat
Genteal
Lotemax
None
Patanol
Pred Forte
Refresh
Rewetting Drops
Systane
Theratears
Travatan
Vigamox
Visine
Xalatan
Other
Last Eye Exam
1 year
2 years
3 years
Other
Doctor?
Primary Vision Correction
Contacts - Soft
Glasses - Fulltime
Glasses - Readers Only
None
OTC Readers
PMMA
RGPs
Other
Back up specs?
Yes
No
Other
Wants new glasses?
Yes
No
Other
Contact Cleaner
Boston
Clear Care
Optifree
Renu
Other
Disposable Contact
2 weeks
daily
monthly
weekly
yearly
Other
Wear Time
>2 hours today
10 hours
12 hours
8 hours
All Day
Extended
Occ. Overnight
Overnight
Other
Days/Week
How many hours comfortably?
Patient General Health
Allergies
Asthma/Respiratory
Blood Disorders
Cancer
Hypertension
Chronic Bronchitis
Chronic Cough
Diabetes
Emphysema
Gastrointestinal Problems
Heart Attack
Stroke
Headaches/Migraines
Kidney Disorders
Psychiatric/Depression
Rheumatoid Arthritis
Thyroid Disorder
Weight Loss/Gain
None of the Above
Family Ocular History
Glaucoma
No
Parents
Sibling
Grandparent
Other
Cataracts
No
Parents
Sibling
Grandparent
Other
Cataracts
No
Parents
Sibling
Grandparent
Other
Retinal Detach
No
Parents
Sibling
Grandparent
Other
Crossed / Lazy
No
Parents
Sibling
Grandparent
Other
Optional
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Other Race
Patient Declined to Specify
White
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Other
Patient Declined to Specify
Preferred Language
English
French
German
Spanish
Other
Notes
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