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Advanced Vision Dr. Spencer Young
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2017-07-06T01:14:30+00:00
Advanced Vision - Dr. Spencer Young, OD
General Information
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
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 Format: MM slash DD slash YYYY
Date of Last Eye Exam
Date Format: MM slash DD slash YYYY
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
Blurred Vision/Distance
Blurred Vision/Near
Double Vision
Eye Strain
Eye Infections
Eye Pain/Soreness
Tired Eyes
Burning Eyes
Itchy Eyes
Dry Eyes
Red Eyes
Watery Eyes
Wandering Eye
Mucus Discharge
Floaters or Spots
See Flashes
See Halos
Poor Night Vision
Headaches
Migraine Headaches
Loss of Vision
Crossed Eyes
Light Sensitivity
Sandy/Gritty Feeling
Poor Color Vision
Droopy Lid
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
Retinal Detachment
High Blood Pressure
Diabetes
Cancer
Heart Disease
Thyroid Disease
Blindness
Cataracts
Glaucoma
Crossed Eyes
Macular Degen
Lupus
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