Eldorado Vision & Optical

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

Gender

Home Phone

Cell Phone

Work Phone

Email

Employer

Marital Status

Primary Medical Insurance

Insurance Type

Insurance Company Name

ID #

Group #

Policy Holder Name

First Last

Insurance Telephone #

Secondary Insurance to Medicare

Insurance Company Name

ID #

Group #

Policy Holder Name

First Last

Insurance Telephone #

Vision Insurance

Insurance Company Name

ID #

Policy Holder Name

First Last

Insurance Telephone #

Referral Information

Individual

First Last

Relationship to you

Did you hear about us from any of the following?

Internet
Facebook
Insurance
Website
Other

If other:

Have you had any changes in last 6-9 months to your:

Distance Vision
Near Vision
Computer Vision

Daily hours on digital devices

Have you experienced any of the following eye problems in the last 6 months?

Itching
Burning
Red
Gritty
Watery
Dry

History of eye diseases, eye injuries, eye surgeries:

Check if you have had any of the following

Glaucoma
Macular Degeneration
Cataracts
Retinal Problems
Droopy Eyelids
Cataract Surgery
Lasik Surgery
Other

If other:

Current Eye Medications

Eyedrops, prescriptions, over-the-counter eye medications, etc.

Date of Last Eye Exam

Doctor

Primary Vision Correction

Contact Lens Type

Days/Week you wear contact lenses

Hours per day you wear contact lenses

Comfortable wearing hours per day

Race

American Indian or Alaska Native
Black or African American
White
Native Hawaiian or other Pacific Islander
Other
Decline

Ethnicity

Hispanic or Latino
Non Hispanic or Latine
Unknown
Decline

Ever Smoked

Yes
No
Current Smoker

How many years?

Do you consume Alcohol?

Yes
No

How often?

Occasional
Social

What kind?

Beer
Wine
Liquor

# of years

Recreational Drugs

Yes
No

Height

Weight

Current Flu Shot

Yes
No

Current Tetanus Shot

Yes
No

Occupation

Hobbies

Your Health Information

Primary Care Physician

Date of last visit to PCP

Reason for visit

Annual Exam
Recent problem
Special Testing

List all Medications

Pregnant or nursing?

Yes
No

Drug Allergies

Injuries, Surgeries, Hospitalizations in last 2 years

Issues in any of the following areas?

Family Health Information

Siblings, Parents, Grandparents