Eyewise Optometry

Date:

Title:

Name:

Last First Middle

Name I like to be called:

Parent/Guardian Name:

First Last

Address:

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

Home Phone:

Mobile Phone:

Work Phone:

Date of Birth:

Age:

Social Security Number:

Sex:

Occupation:

Employer:

Vision Care Insurance:

Email Address:

Primary Medical Insurance:

Primary Care Physician:

Whom may we thank for referring you to our practice?

What is the main reason for your visit?

Do you wear glasses?

Yes
No

Are you interested in glasses?

Yes
No

Do you wear contact lenses?

Yes
No

Are you interested in contact lenses?

Yes
No

Do you have any questions about refractive surgery (ex: LASIK)?

Past, Family, and/or Social History

Is there anything in your past history, family history, or social history which would help us care for you?

Past History

Yes
No

Illnesses, operations, injuries, medications, treatments.

Please explain:

Family History

Yes
No

Diseases, hereditary, risk factors, glaucoma.

Please explain:

Social History

Tobacco
Alcohol
Recreational Drugs

Do you use any of these products?

Review of Systems:

Check all that apply.

Eyes

Allergic/Immunologic

HIV
Hay Fever
Medicine allergies

Constitutional Symptoms

Fever
Weight loss

Cardiovascular

Heart pain
High blood pressure
Vascular disease

Ears, Nose, Mouth, Throat

Sinus problems
Chronic cough
Dry throat/mouth
Chronic ear infections

Endocrine

Diabetes
Thyroid problems
Other glands

Gastrointestinal

Ulcers
Constipation

Genitourinary

Genitals/kidneys/bladder

Hematologic/Lymphatic

Anemia
Bleeding problems
Swelling

Integumentary

Skin
Breast

Musculoskeletal

Arthritis
Rheumatoid arthritis
Muscle pain
Joint pain

Neurological

Headaches
Migraines
Seizures

Psychiatric

Nervous disorders
Depression
Compulsive behavior

Respiratory

Asthma
Shortness of breath
Emphysema
Lung cancer

Please list all medications and any additional pertinent information: