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Garland Vision Source
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2020-09-03T17:20:35+00:00
Garland Vision Source
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Patient Information
Name
*
First
Last
Date of Birth
*
Month
Day
Year
Age
Sex
Male
Female
Height
Weight
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Antarctica
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Chile
China
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Congo, Republic of the
Cook Islands
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Croatia
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Dominican Republic
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El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
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France
French Guiana
French Polynesia
French Southern Territories
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Gambia
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Guinea-Bissau
Guyana
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Heard and McDonald Islands
Holy See
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Hungary
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Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone (or Cell if no home)
*
Cell Phone
Email
*
Patient's Social Security Number
XXX-XX-XXXX
Employer (or School):
Occupation (or Grade):
Spouse (or Parent's) Name:
Spouse (or Parent's) Phone:
Referred by:
Date of Last Eye Exam
Primary Medical Insurance Co:
Vision Insurance Co:
Subscriber's Name:
Subscriber's Date of Birth
Month
Day
Year
Identification#
Group#
Primary Care Physician:
Current Medications (Please list the names of all Rx and over the counter medications, including any eye drops, multi vitamins and/or birth control pills)
Allergies to Medications:
Yes
No
If yes, Please List:
The Federal Government now requires us to collect the following information (please choose only ONE ANSWER for each cagegory):
Language:
English
French
Spanish
Russian
Japanese
Other
Race:
White
Hispanic
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Other
Decline to Answer
Ethnicity:
Caucasian
Native American
German
Hispanic/Latino
Native Hawaiian
Russian
African American
Asian
Other
Decline to Answer
Please communicate with me via:
Phone
E-Mail
Postal
What is your birth order?
Only Child
Other
Other: Please Specify
Do you smoke?
Yes
No
Packs per day?
If former smoker, how long ago did you quit?
Do you drink alcoholic beverages?
Yes
No
Social Only
1-2 Drinks Daily
Alcohol Dependence
Do you use narcotics?
Yes
No
Recreational Use
Chemical Dependence
Do you have a history of sexually transmitted diseases?
Yes
No
Do you have a history of blood transfusion?
Yes
No
Please check all that apply:
Do you currently wear prescription glasses?
Do you currently wear contact lenses
Do you have more than one pair of current prescription glasses
Do you have prescription sunglasses
Have you had LASIK or PRK? If so, what year?
Do you wear bifocals or trifocals?
If so, are you bothered by the lines?
Have you ever been diagnosed or treated for?
Allergies
Cancer
High Blood Pressure
Thyroid Disease
Asthma
Diabetes
Arthritis
High Cholesterol
Kidney Disease
Other:
Have you ever been diagnosed or treated for:
Amblyopia/Lazy Eye
Corneal Abrasion
Glaucoma
Macular Degeneration
Cataracts
Eye Injury
Iritis
Retinal Detachment
Other
Other: Please Specify
Are you currently experiencing any of the following:
Blurry Vision
Double Vision
Floaters/Spots
Itchiness
Trouble seeing at night
Burning
Excessive Tearing
Dry Eyes
Sunlight Sensitivity
Crossed/Turned Eye
Flashes of Light
Headaches
Do you have a family history of any of the following?
Blindness
Retinal Problems
Macular Degeneration
Cataracts
Corneal Problems
Glaucoma
Diabetes
Patient/Guardian Name
First
Last
Date of Birth
MM slash DD slash YYYY
Current Medical Problems
Select All That Apply
Allergy/Immunologic (e.g., Hives, Eczema, Rash, Lumps)
Cardiovascular (e.g., Chest Pain, Palpitations, Difficulty Breathing, Endema)
Constitutional (e.g., Fever, Chills, Weight Gain, Weight Loss)
Endocrine (e.g., Heat/Cold Intolerance, Frequent Urination, Thirst, Appetite)
Gastrointestinal (e.g., Heartburn, Nausea, Constipation, Diarrhea)
Ear/Nose/Mouth/Throat (e.g., Decreased Hearing, Discharge, Dryness, Hoarseness)
Hematologic (e.g., Bruising, Bleeding, Anemia)
Integumentary (e.g., Moles, non-healing lesions, Dryness, Color Changes)
Musculoskeletal (e.g., Muscles/Joint Pain, Stiffness, Back Pain, Joint Swelling)
Neurological (e.g., Dizziness, Fainting, Seizures, Weakness)
Psychiatric (e.g., Nervousness, Depression, Memory Loss, Stress)
Respiratory (e.g., Cough, Sputum, Shortness of Breath, Wheezing)
None
Medical History
Select All That Apply
Asthma
High Blood Pressure
Any Cancer
Cholesterol Problems
Depression
Diabetes
Emphysema
Hearth Problems
Kidney Disease
Liver Disease
Osteoporosis
Seizures
Strokes
Thyroid Problems
Surgery
Allergies (Seasonal)
Allergies to Medication
None
Allergies to Medications: Please List
All Current Medications
Please List with Dosage
Patient Eye History. Select all that apply
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters/Spots
Light Flashes
Frequent Eye Infections/Styes
Glaucoma
Glaucoma Suspect
Iritis/Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Other
None
Other: Please Specify
Has Patient's Family Experienced Any of These Medical Conditions? Select all that apply.
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters/Spots
Light Flashes
Frequent Eye Infections/Styes
Glaucoma
Glaucoma Suspect
Iritis/Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Other
None
Other: Please Specify
Any Patient Surgeries? Select all that apply.
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser
Glaucoma Surgery
LASIK/PRK
Retinal Laser
Retinal Surgery
Retinal Injections
RK Incisions
Yag (Laser After Cataract)
Other
None
Other: Please Specify
Has Patient's Family Undergone Any of The Procedures below? Select all that apply.
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser
Glaucoma Surgery
LASIK/PRK
Retinal Laser
Retinal Surgery
Retinal Injections
RK Incisions
Yag (Laser After Cataract)
Other
None
Other: Please Specify
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