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Grand Island Optical Patient History Form
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2017-08-06T22:19:01+00:00
Grand Island Optical Patient History Form
Date:
MM slash DD slash YYYY
SS#:
Date of Birth:
MM slash DD slash YYYY
Mr
Mstr.
Miss
Mrs.
Ms
Single
Married
Separated
Divorced
Widowed
Name:
First
Middle
Last
Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
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 #:
Cell #:
Email Address:
Current Occupation:
Employer:
How did you hear about our office?
Health Insurance Name:
Health Insurance Identification Number:
Health Insurance Subscriber's Name:
Vision Insurance Name:
Vision Insurance Identification Number:
Vision Insurance Subscriber's Name:
Health Insurance Subscriber Information (if different from patient)
Name
First
Last
DOB:
MM slash DD slash YYYY
SS#:
Person responsible for payment:
Relationship to patient:
Address (if different):
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
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
Reason for Visit:
Eye Infection or Problem
New Patient Vision Exam
Established Patient Eye Exam
Contact Lens Exam
Contact Lens Follow-up
Other (Please specify below)
Additional Information:
Do you wear Glasses?
Yes
No
Please check all that apply:
Always
Only while driving
For reading
Sunglasses
Computer
Do you wear Contact Lenses?
Yes
No
If Yes, what type of Contact Lenses?
Disposable Soft
Regular Soft
Gas Permeable
Other (Please specify below)
Additional Information:
Have you ever had eye surgery?
Yes
No
Date of Surgery:
MM slash DD slash YYYY
Type of Surgery:
How many hours per day do you use a computer?
0-2
2-4
4-6
6-8
8+
Are you experiencing any of the following?
Please check all that apply:
Blurred Distance Vision
Blurred Near Vision
Burning Eyes
Double Vision
Dry Eyes
Eye Strain
Flashes of Light
Gritty Feeling Eyes
Headaches
Itchy Eyes
Loss of Vision
Night Vision Problems
Objects Floating in Vision
Pain in Eyes
Red Eyes
Sensitivity to Light
Watery Eyes
Name of Family Doctor:
Are you currently under the care of a physician?
Yes
No
If yes, please list reasons:
Are you Pregnant?
Yes
No
Are you Nursing?
Yes
No
Do you currently experience, or have in the past, any problems in the following areas?
Please check all that apply:
Allergy
Blood
Cardiovascular
Constitutional
Ear, Nose, Throat, Mouth
Endocrine
Gastrointestinal
Genitourinary
Hematologic/Lymphatic
Immunologic
Integumentary (skin)
Musculoskeletal
Neurologic
Psychiatric
Respiratory
Indicate any
family history,
including yourself, for the following conditions.
Please check all that apply:
Blindness
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Cataract
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Glaucoma
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Macular Degeneration
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Retinal Detachment/Disease
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
AIDS/HIV
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Arthritis
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Cancer
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Diabetes
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Heart Disease
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
High Blood Pressure
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Kidney Disease
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Thyroid Disease
Yourself
Mother
Father
Sister
Brother
Grandparent
Child
Do you use tobacco products?
Yes
No
Do you drink alcohol?
Yes
No
Do you use other substances?
Yes
No
Do you participate in Sports?
Yes
No
If Yes, please list which sports you participate in:
Medication & Allergy List
Pharmacy Name
Pharmacy Address
Pharmacy City
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING, INCLUDING EYE MEDICATIONS: Please include prescriptions (ex. Lipitor, Fosamax), over-the-counter medicines (ex. Aspirin, Antacids) and herbals (ex. Gingko, Ginseng). Also include the medications taken as needed (ex. Nitroglycerin).
Please include Name of Medication (Lipitor, Artificial Tears), Dosage (ex. 10 mg, 250 mg, etc), and Directions (ex. Two times per Day)
LIST ALLERGIES AND DESCRIBE REACTION:
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