Eyeworks Optical

Eyeworks Opticaladmin2019-02-20T19:41:49+00:00

Eyeworks Optical

Name*
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Email*
Date of Birth*
MM slash DD slash YYYY
Age
Occupation
Employer
Last Eye Exam*
MM slash DD slash YYYY
Where
Name of Dr.*
First Last
Primary Care Physician
Pharmacy Name and Location
Do you wear glasses?*
How old are they?
How often/when do you wear them?
Do you wear Contact Lenses?*
Brand
Solution
Do you sleep in them?
Are you interested in trying contact lenses?
Are you interested in refractive surgery(LASIK)?
Reason for today's visit?*
List All Medications You Are Taking*
Height
Weight
List all allergies
Allergy Reaction Severity(Mild/Moderate/Severe)
Past Ocular History: (Please mark all that apply)*
- Amblyopia (lazy eye)
- Astigmatism
- Cataracts
- Corneal Disorder
- Diabetic Retinopathy
- Dry Eye Syndrome
- Glaucoma
- Hyperopia (Farsighted)
- Iritis/Uveitis
- Macular Degeneration
- Myopia (Nearsighted)
- Retinal Detachment
- No history of eye problems
Past Ocular History Not Listed Above
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*
Ocular Surgeries Left, Right or Both Eyes
Other Medical History?

Anemia, Headache, Liver Disease, Arthritis, Hearing Loss, Lupus etc...
Family History (Family History includes your parents, grandparents, siblings, and your children)*
- Blindness
- Cataract
- Glaucoma
- Diabetes
- High Blood Pressure
- Cancer
- Heart Disease
- Thyroid Disease
- Arthritis
- Stroke
- Macular Degeneration
- None of the Above
Social History
Do You Use Tobacco Products?*
- Current every day smoker
- Former smoker
- Current some day smoker
- Never smoked
Do You Drink Alcohol?*
- No
- Yes
If yes, how much and how often?
Drug Use?*
- No
- Yes
If yes, which and how long?
Review of Systems: (Please mark all that apply)
Eyes
- Previous Surgery
- Contact Lens
- Pain
- Double Vision
- Glaucoma
- Cataracts
- Macular Degeneration
- Dry Eyes
- Flashes
- Floaters
Ear, Nose, and Throat
- Hard of Hearing
- Ringing in Ears
- Vertigo
Cardiovascular
- Chest Pain
- Dizziness
- Fainting Spells
- Shortness of Breath
- Irregular Heart Beat
- Difficulty Lying Flat
Constitutional
- Fatigue / Weakness
- Fever
- Weight Gain / Loss
Respiratory
- Cough
- Congestion
- Wheezing
- Asthma
Gastrointestinal
- Heartburn
- Nausea / Vomiting
- Jaundice / Hepatitis
Genitourinary
- Pain / Difficulty
- Blood in Urine
- History of Kidney Stones
- History of STD's
Psychiatric
- Anxiety / Depression
- Mood Swings
- Difficulty Sleeping
Endocrine
- Increased Thirst
- Increased Hunger
- Increased Urination
- Increased Sweating
- Fingernail Changes
Blood/Lymph Nodes
- Easy Bruising
- Gums Bleed Easy
- Prolonged Bleeding
- Heavy Aspirin Use
Musculoskeletal
- Stiffness
- Arthritis
- Joint Pain / Swelling
Skin
- Rash / Sores
- Lesions
- Hives / Eczema
Neurological
- Seizures
- Weakness / Paralysis
- Numbness
- Tremors
Immunologic
- Hives
- Itching
- Runny Nose
- Sinus Pressure
Patient Signature
Date
MM slash DD slash YYYY
Reviewed By
Date
MM slash DD slash YYYY

Allergy	Reaction	Severity(Mild/Moderate/Severe)

Ocular Surgeries	Left, Right or Both Eyes

Eyeworks Optical

Social History

Review of Systems: (Please mark all that apply)