Jamison Optical

Name

First Last

Date of Birth

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:

Employer

Emergency Contact Name

Emergency Contact Phone #

Primary Reason for visit:

How did you find our office?

Date of last eye exam

Have you ever been diagnosed with the following conditions?

(CHECK ALL THAT APPLY)

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

Date of last medical exam:

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?