Garland Vision Source

Today's Date

Patient Information

Name*

First Last

Date of Birth*

Age

Sex

Male
Female

Height Weight

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone (or Cell if no home)*

Cell Phone

Email*

Patient's Social Security Number

XXX-XX-XXXX

Employer (or School):

Occupation (or Grade):

Spouse (or Parent's) Name:

Spouse (or Parent's) Phone:

Referred by:

Date of Last Eye Exam

Primary Medical Insurance Co:

Vision Insurance Co:

Subscriber's Name:

Subscriber's Date of Birth

Identification#

Group#

Primary Care Physician:

Current Medications (Please list the names of all Rx and over the counter medications, including any eye drops, multi vitamins and/or birth control pills)

Allergies to Medications:

Yes
No

If yes, Please List:

The Federal Government now requires us to collect the following information (please choose only ONE ANSWER for each cagegory):

Language:

English
French
Spanish
Russian
Japanese
Other

Race:

White
Hispanic
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Other
Decline to Answer

Ethnicity:

Please communicate with me via:

Phone
E-Mail
Postal

What is your birth order?

Only Child
Other

Other: Please Specify

Do you smoke?

Yes
No

Packs per day?

If former smoker, how long ago did you quit?

Do you drink alcoholic beverages?

Yes
No

Social Only
1-2 Drinks Daily
Alcohol Dependence

Do you use narcotics?

Yes
No

Recreational Use
Chemical Dependence

Do you have a history of sexually transmitted diseases?

Yes
No

Do you have a history of blood transfusion?

Yes
No

Please check all that apply:

Do you currently wear prescription glasses?
Do you currently wear contact lenses
Do you have more than one pair of current prescription glasses
Do you have prescription sunglasses
Have you had LASIK or PRK? If so, what year?
Do you wear bifocals or trifocals?

If so, are you bothered by the lines?

Have you ever been diagnosed or treated for?

Allergies
Cancer
High Blood Pressure
Thyroid Disease
Asthma
Diabetes
Arthritis
High Cholesterol
Kidney Disease

Other:

Have you ever been diagnosed or treated for:

Amblyopia/Lazy Eye
Corneal Abrasion
Glaucoma
Macular Degeneration
Cataracts
Eye Injury
Iritis
Retinal Detachment
Other

Other: Please Specify

Are you currently experiencing any of the following:

Do you have a family history of any of the following?

Blindness
Retinal Problems
Macular Degeneration
Cataracts
Corneal Problems
Glaucoma
Diabetes

Garland Vision Source

Step 1 of 2

Patient Information

Current Medical Problems

Medical History

All Current Medications