Jerry Jacobs, OD

Welcome to our Office

Name

First Last

Date of Birth

Social Security Number

Address

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

Email

Home Phone

Cell Phone

Employer

Occupation/Position

If Child, School and Grade

Parent's Name

Referred By

Vision Insurance

ID #

Medical Insurance

ID #

Supplm Ins.

Primary Member

ID #

DOB#

Primary Care Physician

Are you under a physician's care?

Yes
No

Current Medicaitons

If taking any, please list

Medication Allergies

If you have any, please list

Tobacco Use

Never Smoked
Current Smoker
Former Smoker

Alcohol Use

If yes, how often?

Vision History

Last Eye Exam

By Whom

Do you wear glasses?

If so, when?

Is your vision blurred at:

Distance
Night
Near
Computer
Other

Are you interested in new glasses?

Yes
Possible, if needed or changed
Not at this time

Contact Lenses

If not wearing contact lenses, are you interested in being fitted?

Yes
No

If currently wearing contact lenses, do you need new/more lenses?

Yes
No

Type of contact lenses

Soft
Gas Permeable
Other

How are they worn

Daily Wear
Extended Wear
Occasional Overnight Wear

Percent of time worn

100%, 50%, occasionally, etc.

Are your lenses comfortable?

Do you see well with your current contact lenses?

Ocular Symptoms

Check if occur

Ocular Conditions

Amblyopia (lazy eye)
Strabismus (eye turn)
Color Deficient
Cataract
Glaucoma
Macular Degeneration
Retinal Tear/detachment
Eye Injury
Eye Surgery

Medical History

Do you have any of the following?

High Blood Pressure
High Cholesterol
Heart Condition
Arthritis
Allergies
Sinus Issues
Anxiety/Depression
HIV +

Have you been diagnosed with Diabetes?

If yes, how long ago?

Headaches

If yes, how often and what part of the head?

Are they dull, sharp, severe, migraine? When do they occur?

Family Medical History

Glaucoma
Diabetes
Macular Degeneration
Crossed eyes

Are you interested in a refractive surgery procedure? (Lasik, PRK, etc.)

Yes
No
Possibly later

Other conditions which may be significant?

Signature

I've been given the opportunity to review the Notice of Privacy Practice.

Date