Advanced Vision Dr. Spencer Young

General Information

Name

First Last

Date of Birth

Gender

Male
Female
Other

SSN

Marital Status

Married
Single
Divorced
Widowed

Home Phone

Work Phone

Cell Phone

Employer/School

Occupation/School Grade

Email

Sport/Hobbies

Emergency Contact

First Last

Relation

Phone #

Case History/Reason for Visit

Date of Last Medical Exam

Date of Last Eye Exam

Primary Physician/Clinic

Clinic/Eye Doctor's Name

Do you wear glasses?

Yes
No
All the time
Sometimes
Work Only
Reading Only
Driving Only

How old are your present glasses?

Do you wear prescription Sun Wear?

Yes
No

Do you wear contacts?

If yes, please list what type

Solution Used?

Wearing Schedule

Daily
Overnight

Replacement Schedule

Daily
2 weeks
Monthly
Yearly

Have you ever had eye injuries?

If yes, which eye?

Have you ever had eye surgeries?

If yes, why?

Have you ever used eye medication?

If yes, why?

Are you currently pregnant or nursing?

Yes
No
N/A

Have you ever been diagnosed with Cataracts?

If yes, when were you diagnosed?

Have you ever been diagnosed with Glaucoma?

If yes, when were you diagnosed?

Have you ever been diagnosed with Macular Degeneration?

If yes, when were you diagnosed?

What are your visual symptoms (with or without glasses or contacts)?

Please check any that apply

Personal Medical History (Review of Systems)

Please check any that apply

Cardiovascular

None
Hypertension
Stroke
Heart Disease
Vascular Disease
Other

Constitutional

None
Cancer
Trauma/Large Volume Blood Loss
Developmental Disability
Other

Neurological

None
Multiple Sclerosis
Cerebral Palsy
Tumor
Other

Hermatological

None
Anemia
Leukemia
Other

Dermatologic

None
Rosacea
Psoriasis
Other

Endocrine

None
Non-Insulin Dependent Diabetes
Insulin Dependent Diabetes
Thyroid Problem
Hormonal Dysfunction
Other

Ocular

None
Glaucoma
Macular Degeneration
Detached Retina
Other

Gastrointestinal

None
Crohn's
Colitis
Other

Allergies

Please list physical reaction's to above allergies

Respiratory

None
Asthma
Bronchitis
Emphysema
COPD
Other

Psychiatric

None
ADHD
Depression
Schizophrenia
Other

Immunologic

None
AIDS or HIV
Rheumatoid Arthritis
Lupus
Neurofibromatosis
Other

Ear/Nose/Throat

None
Hearing Loss
Upper Respiratory Infection
Other

Alcohol Use

If yes, how much?

Tobacco Use

If yes, how much?

Please list any medications and/or drugs that you are taking (including herbal)

FAMILY HISTORY: Has anyone in your family (grandparents, parents, siblings, children, living or deceased) been diagnosed with