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Eye Desire Eye Care & Optical Boutique
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2017-07-06T01:14:26+00:00
Eye Desire Eye Care & Optical Boutique
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Name of Spouse or Parent
First
Last
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
*
MM slash DD slash YYYY
Home Phone
*
Work Phone
MM slash DD slash YYYY
Cell Phone
Social Security Number
Email
How did you first hear about our office?
Internet
Insurance
Community Event
Other
Friend/Relative
Physician
Other
Friend/Relative
Physician
Employer (or School)
Occupation (or Grade)
What is the main purpose for this visit?
Any problems with your present contact lenses or glasses?
Vision Insurance
Medicare
VCP
VSP
Eyemed
Humana
Other
Other
Medical Insurance
How do you plan on settling your account?
Cash
Check
Credit Card
Keep Credit Card on File?
Financing
VISUAL NEEDS
Are you planning to get new glasses?
Yes
No
Are you planning to get new contacts?
Yes
No
Do You...(Check those that apply)
Work at a computer?
Have only one pair of glasses?
Wear bifocals?
Want information on progressive lenses?
Prefer not to wear glasses at times?
Spend a lot of time outdoors?
Ever find a need for prescription sunglasses?
Have problems with glare or reflections (ex: night driving)?
Do work requiring safety glasses?
Participate in sport activities?
Want information about vision correction without surgery (GMT)?
Want information about LASIK surgery?
Wear or ever tried wearing contacts?
What kind of sport activities?
What kind of contacts?
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. This information is important for medical purposes as well as compliance with insurance directives.
Yes, I would prefer to discuss my Social History information directly with my doctor
Yes
Do you use Tobacco Products?
Yes
No
Do you drink alcohol?
Yes
No
Are you HIV Positive?
Yes
No
Do you experience...(Check those that apply)
Blurry Distance Vision
Blurry Near Vision
Double Vision
Trouble Seeing at Night
Eye Strain
Headaches
Dryness
Redness
Burning
Water Eyes
Itchiness
Gritty Feelings
Soreness
Flashes of Light
Floaters
Glare or Reflection
Sudden Loss of Vision
Sensitivity to Light
Fainting or Dizziness
Nausea
Other
Other
Medical History
Allergies
Asthma
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Cancer
Arthritis
Kidney Problems
Nerves
Skin Disorder
Eye Injury
Eye Surgery
Cataracts
Glaucoma
Other
Other
Current Medications (RX or over the counter)
Please give us the name of any Antihistamines you are taking:
Please give us the name of any Blood Pressure Pills you are taking:
Please give us the name of any Diuretics (Water Pills) you are taking:
Please give us the name of any Oral Contraceptives you are taking:
Please give us the name of any Cholesterol Medications you are taking:
Please give us the name of any Eye Drops you are taking:
Please give us the name of any Allergies to Medications you have:
Please list any other medications you are taking:
Use the plus symbol to the right of the list box to add more medications to your list.
Family Medical History
Blindness
Glaucoma
Diabetes
High Blood Pressure
Cancer
Other
Blindness: Relationship to you
Glaucoma: Relationship to you
Diabetes: Relationship to you
High Blood Pressure: Relationship to you
Cancer: Relationship to you
Describe the Other Family Medical History and the relationship to you
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