Family Vision Center

Name

Title First M.I. Last

Date of Birth

Age

Sex

Height

Weight

Address

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

Home Phone

Daytime Phone

Cell Phone

Email

Social Security No.

Marial Status*

Single
Married
Widowed
Divorced

Name of Employer

Occupation

Employer Address

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

If child, parent's or guardians' name

Relationship

If married, name of spouse

Souse DOB

Person financially responsible for this account

Vision Insurance

Vision Ins. Member name

VI Member ID#

VI DOB

Primary Medical Insurance

Primary MI Member Name

Primary MI Member ID#

Primary MI Member DOB

Secondary Medical Insurance

Secondary MI Member Name

Secondary MI Member ID#

Secondary MI Member DOB

Nearest relative or friend not residing with you

Relationship

Phone

How did you hear of us?

phone book
insurance list
internet
friend/family
physician office
other

What is the primary reason for today’s visit?

I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.*

I hereby authorize the use or disclosure of my individually identifiable health information as described in the “NOTICE OF PRIVACY PRACTICES” document.

Date

What is your general health?

Excellent
Good
Fair
Poor

Do you have problems with any of these symptoms? (Check all that apply.)

Type of diabetes and date of diagnosis

Please explain above

Do you smoke?

Yes
No

Alcohol intake?

Yes
No

Allergies to medication?

Yes
No

Which medications?

Current medications (If none, leave blank)

Have you had any operations / surgery?

Yes
No

What kind?

Name of Family Doctor

Family History (Check all that apply)

High Blood Pressure
Macular Degeneration
Diabetes
Retinal Detachment
Glaucoma
Cataracts

High Blood Pressure - Relation to Patient

Macular Degeneration - Relation to Patient

Diabetes - Relation to Patient

Retinal Detachment - Relation to Patient

Glaucoma - Relation to Patient

Cataracts - Relation to Patient

Date of last eye exam

Do you have any eye conditions or problems?

Yes
No

What kind?

Have you had any eye operations?

Yes
No

Type and Date

Have you had an eye injury?

Yes
No

Kind of Injury and Date

Do you have: (Check all that apply)

Glaucoma?
Cataracts?
Dry Eyes?
Macular Degeneration?
Retinal Detachment?
Blurred Vision?

Are you currently experiencing any of the following? (Check all that apply)

Do you wear: (Check all that apply)

Glasses
Contacts

Type of Lens

Soft
Hard

Average contact lens daily wear time

Average contact lens wear number of days per week

Additional Information