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Jamison Optical
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2017-07-06T01:14:31+00:00
Jamison Optical
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Preferred phone:
Home Phone
Cell Phone
Work Phone
Home Phone #
Cell Phone #
Work Phone #
Email
Insurance Company / Self Pay
Insurance primary policy holder name & date of birth
Insurance ID/Policy# & Group#
Occupation/Grade in School:
MM slash DD slash YYYY
Employer
Emergency Contact Name
Emergency Contact Phone #
Primary Reason for visit:
How did you find our office?
Insurance
Google
Yelp
Family
Ad/News/Print
Referred by patient
Other
Date of last eye exam
Have you ever been diagnosed with the following conditions?
(CHECK ALL THAT APPLY)
Cataracts
Macular degeneration
Glaucoma
Diabetes
Diabetic retinopathy
Dry eye
Eye Infection, Inflammation or allergy
Floaters/flashes of light
Injury
Iritis/Uvetis
Strabismus/lazy eye
Retina defects or degenerations
Are you having any of the following eye concerns?
(CHECK ALL THAT APPLY)
Redness
Burning
Itching
Tearing
Discharge
Are you having any of the following vision concerns?
(CHECK ALL THAT APPLY)
Blurred vision
Eyestrain
Eye pain
Severe sensitivity to lights
Headache
Poor night vision
Bothersome night glare
Double vision
Total loss of vision
Do you currently wear glasses?
Yes
No
If so, when? (e.g. distance, reading, computer)
Do you wear contacts?
Yes
No
When?
How many hours of computer use, per day?
Are you using:
Computer with paperwork
Multiple computer screens
Laptop
Do you have any of these vision problems?
Poor reading skills or low reading performance
Inconsistent sports vision performance
Slowness when shifting focus
Difficulty with 3-D images, movies or TV
Describe any special outdoor demands:
Night driving
Outdoors in direct sun
Reading outdoors
Irritated contact lenses
Are you interested in? Check all that apply
New frames
Thinner lenses
Reducing glare
New lens technology
Prescription sunglasses
Computer eyeglasses
Reading eyeglasses
Sport eyeglasses
More comfortable contact lenses
Daily contact lenses
Date of last medical exam:
MM slash DD slash YYYY
Primary clinic/Physician:
Do you have any of the following medical concerns? Check all that apply
Developmental Disabilities
Cancer
Fatigue
Weight loss/gain
Ear/Nose/Throat - Check all that apply
Hearing loss
Sinusitis
Dry Mouth
Laryngitis
Neurology - Check all that apply
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Stroke/CVA
Migraine
Autism spectrum disorder
Psychology - Check all that apply
Depression
Attention deficit
Anxiety disorder
Bipolar disorder
Cardiovascular - Check all that apply
High blood pressure
Stroke/CVA
Heart Disease
Vascular Disease
Congetive heart failure
Respiratory - Check all that apply
Asthma
Bronchitis
Emphysema
Chronic obstruction
Sleep apnea
Other
Gastrointestinal - Check all that apply
Crohn’s
Colitis
Ulcer
Acid reflux
Celiac disease
Genitourinary - Check all that apply
Kidney disease
Prostate disease/cancer
STD
Benign prostate hyper trophy
Muscular/Skeleton - Check all that apply
Arthritis
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Gout
Skin - Check all that apply
Eczema
Rosacea
Psoriasis
Cold Sores
Shingles
Endocrine - Check all that apply
Type 2 Diabetes Mellitus
Type 1 Diabetes Mellitus
Thyroid dysfunctin
Hormonal dysfunction
Hematologic/Lymphatic - Check all that applies
Anemia
Large Blood loss
Ulcer
High cholesterol
Allergic/Immunologic
Rheumatoid Arthritis
Lupus
Sjogren's Syndrome
List Current Medications
Do you have any allergies to medications?
Yes
No
If yes, please list:
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Family History: Does anyone in your family have any of these conditions?
Cancer
Diabetes
High blood pressure
High cholesterol
Cataracts
Macular degeneration
Glaucoma
Strabismus/Lazy eye
Cancer - Relation to patient
Diabetes - Relation to patient
High blood pressure - Relation to patient
High cholesterol - Relation to patient
Cataracts - Relation to patient
Macular degeneration - Relation to patient
Glaucoma - Relation to patient
Strabismus/Lazy eye - Relation to patient
Lifestyle: What are your Hobbies?
Do you play sports?
Do you wear safety eyewear?
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