Enterprise Optometry

Name

First Last

Today's Date

Date of Birth

Address

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

Gender

Male
Female

Occupation

Primary Care Physician

Social Security Number

Please choose your preferred communication method

Phone
Text message on cell phone
E-Mail

Email

Home Phone

Cell Phone

Who are you insured by?

Fill in none if not insured.

May we ask how you were referred here?

Prior patient
Yellow Pages
Internet
Location
Friend/relative

Name of friend/relative that referred you.

Visit Information

Please describe the main reason for this examination.

Which Eye? Eyelid? If other, please describe here.

How severe is it?

Mild, moderate, intense, etc.

Please check other eye concerns

Please explain the above concerns or other concerns.

List all of your current medications

If you have a written list, you may bring it in instead.

Briefly list major surgeries

Include eye surgeries, Lasik, PRK, etc.

Personal History

Cataract

Yes
No

(Current or removed)

Eye Turn

Yes
No

Loss of peripheral vision

Yes
No

Blindness

Yes
No

Eye Turn

Yes
No

Glaucoma

Yes
No

Macular Degeneration

Yes
No

Retinal Detachment

Yes
No

Other

Review of Systems

Please indicate below if you have or ever had problems with the following conditions:

Allergic/Immunologic

None
Lupus (SLE)
Rheumatoid Arthritis
Environmental Allergies
Season Allergies
Other (i.e., Latex)

Cardiovascular

None
High Blood Pressure
Heart Disease
Stroke
High Blood Cholesterol
Other

Hematologic/Lymphatic

None
Anemia
Leukemia
Bleeding Disorder
Other

Ear, Nose, and Throat

None
Sinusitis
Upper Respiratory Tract Infection
Other

Endocrine/Glands

None
Diabetes
Hormone Dysfunction
Thyroid Dysfunction
Other

Neurological

None
Multiple Sclerosis
Epilepsy
Tremors
Other

Gastrointestinal

None
Crohn's Disease
Colitis
Acid Reflux/Ulcer
Other

Respiratory

None
Asthma
Bronchitis
Emphysema
Other

Skin/Integumentary

None
Eczema
Rosacea
Psoriasis
Other

Muscle/Skeletal

None
Arthritis
Fibromyalgia
Ankylosing Spndylitis
Other

Psychiatric

None
Depression
Bi-Polar
Schizophrenia
Other

Genital/Urinary

None
Urinary Tract Infection
HIV Positive
Other

General Health

None
Weight loss/gain
Fever
Fatigue
Other

Tobacco Use

Never Smoked
Current
Former Smoker

Alcohol Use

None
Occasional
Frequent

Non-Prescription drug use

Signature

Patient or parent/guarding

Date

In compliance of guidelines for electronic records, this information will be scanned into your new electronic chart. Thank you.

Day Phone

Please choose your preferred communication method

Phone
Text message on cell phone
E-Mail

Optional

Cell Phone

E-Mail address

Other

Home Phone

Cell Phone

E-Mail address

Please sign to acknowledge that this form is current

Date

Are you pregnant?

Yes
No

Are you breast feeding?

Yes
No